Healthcare Provider Details

I. General information

NPI: 1144357310
Provider Name (Legal Business Name): PRESTIGE RESIDENTIAL COMMUNITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44882 MISSION RD
PENDLETON OR
97801-9293
US

IV. Provider business mailing address

7700 NE PARKWAY DR SUITE 300
VANCOUVER WA
98662-6648
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-7157
  • Fax: 541-276-3093
Mailing address:
  • Phone: 360-735-7155
  • Fax: 360-735-9416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. GREGORY J VISLOCKY
Title or Position: MANAGING MEMBER
Credential:
Phone: 360-735-7155