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General NPI Number Information
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NPI Number | 1487975959
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Entity Type | Organization
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Legal Business Name | MIRABELLA AT SOUTH WATERFRONT
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Dates
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Enumeration Date | 06/18/2010
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Last Update Date | 12/02/2025
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Provider Practice Location Address
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Address Line | 3550 S BOND AVE
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City | PORTLAND
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State | OR
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Zip | 97239-4507
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Country | US
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Telephone | 503-688-6400
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Fax |
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Provider Business Mailing Address
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Address Line | 3550 S BOND AVE
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City | PORTLAND
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State | OR
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Zip | 97239-4507
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Country | US
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Telephone | 503-688-6400
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | SHARON VAN EATON
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Credential |
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Telephone | 503-901-2939
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | 1233196437
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 311500000X
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Taxonomy Name | Alzheimer Center (Dementia Center)
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License Number | 1753514587
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License Number State | OR
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Taxonomy #4
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 1291022896
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License Number State | OR
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Taxonomy #5
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number |
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License Number State |
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