Healthcare Provider Details

I. General information

NPI: 1629224449
Provider Name (Legal Business Name): VILLAGE HEALTH CARE I, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 SE 182ND AVE
GRESHAM OR
97030-5036
US

IV. Provider business mailing address

3955 SE 182ND AVE
GRESHAM OR
97030-5036
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-0183
  • Fax: 503-666-6609
Mailing address:
  • Phone: 503-665-0183
  • Fax: 503-666-6609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1124599635
License Number StateOR

VIII. Authorized Official

Name: MR. ALAN JESSE MARCOFF
Title or Position: CONTROLLER
Credential:
Phone: 503-665-0183