Provider Demographics
NPI:1043086002
Name:THRIVE AGE
Entity Type:Organization
Organization Name:THRIVE AGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:POLLY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BANGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-860-1655
Mailing Address - Street 1:3939 N MARINE DR SLIP 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-7769
Mailing Address - Country:US
Mailing Address - Phone:503-860-1655
Mailing Address - Fax:
Practice Address - Street 1:3939 N MARINE DR SLIP 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-7769
Practice Address - Country:US
Practice Address - Phone:503-860-1655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care