Healthcare Provider Details

I. General information

NPI: 1306556154
Provider Name (Legal Business Name): GRESHAM OF OLYMPUS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3457 NE DIVISION ST
GRESHAM OR
97030-4602
US

IV. Provider business mailing address

2205 E RIVERSIDE DR STE 100
EAGLE ID
83616-7621
US

V. Phone/Fax

Practice location:
  • Phone: 208-401-9600
  • Fax: 208-314-0639
Mailing address:
  • Phone: 208-401-9600
  • Fax: 208-314-0639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: STEVE LAFORTE
Title or Position: DIRECTOR OF CORPORATE AFFAIRS
Credential:
Phone: 208-401-9600