MEDICARE: WILLAMETTE MANOR, 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1942162631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLAMETTE MANOR, INC

Provider Business Mailing Address
First Line	:	176 W C ST
Second Line	:
City	:	LEBANON
State	:	OR
Zip	:	97355-3193
Country	:	US
Telephone Number	:	541-258-8178
Fax Number	:	541-258-8197

Provider Business Practice Location Address
First Line	:	176 W C ST
Second Line	:
City	:	LEBANON
State	:	OR
Zip	:	97355-3193
Country	:	US
Telephone Number	:	541-258-8178
Fax Number	:	541-258-8197

Authorized Official
Title or Position	:	PRESIDENT/ COO
Name	:	CARL MASON
Credential	:
Telephone Number	:	503-826-5190

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/01/2025

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Directions to “WILLAMETTE MANOR, INC ” Practice Location

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