MEDICARE: CONCEPTS IN COMMUNITY LIVING, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3104A0630X	Assisted Living Facility (Behavioral Disturbances)

General Provider Information

NPI Number	:	1619592193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONCEPTS IN COMMUNITY LIVING, INC.

Provider Business Mailing Address
First Line	:	15900 SE 82ND DR
Second Line	:
City	:	CLACKAMAS
State	:	OR
Zip	:	97015-9502
Country	:	US
Telephone Number	:	503-255-4647
Fax Number	:

Provider Business Practice Location Address
First Line	:	1337 SW WASHINGTON ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97205-2328
Country	:	US
Telephone Number	:	503-223-2144
Fax Number	:

Authorized Official
Title or Position	:	EVP FINANCE & ADMINISTRATION
Name	:	PETER VERDIECK
Credential	:
Telephone Number	:	503-327-5700

Provider Enumeration Date	:	06/10/2020
Last Update Date	:	06/10/2020

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