Provider Demographics
NPI:1073262333
Name:PENNINGTON GARDENS SL, LLC
Entity Type:Organization
Organization Name:PENNINGTON GARDENS SL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF ORG DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-675-3925
Mailing Address - Street 1:560 1ST ST STE 104
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3273
Mailing Address - Country:US
Mailing Address - Phone:503-675-3925
Mailing Address - Fax:
Practice Address - Street 1:977 S PENNINGTON DR
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5658
Practice Address - Country:US
Practice Address - Phone:480-814-9046
Practice Address - Fax:480-814-9058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-22
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ295255Medicaid