Healthcare Provider Details

I. General information

NPI: 1083356133
Provider Name (Legal Business Name): NEW LIFE HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2022
Last Update Date: 04/10/2022
Certification Date: 04/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 NE COUNTRY CLUB AVE
GRESHAM OR
97030-6016
US

IV. Provider business mailing address

1070 NE COUNTRY CLUB AVE
GRESHAM OR
97030-6016
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-9333
  • Fax:
Mailing address:
  • Phone: 503-491-9333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LUCY MACHUA
Title or Position: DIRECTOR
Credential:
Phone: 314-372-7821