Provider Demographics
NPI:1093384133
Name:WELLTOWER TENANT GROUP LLC
Entity Type:Organization
Organization Name:WELLTOWER TENANT GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RISK & COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-597-4906
Mailing Address - Street 1:7420 SW BRIDGEPORT RD STE 105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7790
Mailing Address - Country:US
Mailing Address - Phone:503-597-4906
Mailing Address - Fax:
Practice Address - Street 1:320 LAKE HAVASU AVE N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-4701
Practice Address - Country:US
Practice Address - Phone:928-855-8099
Practice Address - Fax:928-855-6666
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLTOWER TENANT GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ092050Medicaid