Healthcare Provider Details

I. General information

NPI: 1023243508
Provider Name (Legal Business Name): SISTERE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2009
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 W POWELL BLVD
GRESHAM OR
97030-6843
US

IV. Provider business mailing address

PO BOX 582
GRESHAM OR
97030-0137
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-5193
  • Fax: 503-665-8454
Mailing address:
  • Phone: 503-665-5193
  • Fax: 503-665-8454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number320800000X
License Number StateOR

VIII. Authorized Official

Name: MS. SHANNAN MAYS
Title or Position: ADMINISTRATER
Credential:
Phone: 503-665-5193