MEDICARE: WELL FRONTIER TENANT, LLC

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1720549041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELL FRONTIER TENANT, LLC

Provider Business Mailing Address
First Line	:	7420 SW BRIDGEPORT RD STE 105
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97224-7790
Country	:	US
Telephone Number	:	503-597-4906
Fax Number	:	503-443-1919

Provider Business Practice Location Address
First Line	:	8915 SE MONTEREY AVE
Second Line	:
City	:	HAPPY VALLEY
State	:	OR
Zip	:	97086-7509
Country	:	US
Telephone Number	:	503-654-3200
Fax Number	:	503-654-3800

Authorized Official
Title or Position	:	AUTHORIZED REP.
Name	:	GREGORY A. RODERICK
Credential	:
Telephone Number	:	503-443-1818

Provider Enumeration Date	:	03/28/2019
Last Update Date	:	03/28/2019

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