Provider Demographics
NPI:1114543501
Name:CLEARWATER SPRINGS AL GR, LLC
Entity Type:Organization
Organization Name:CLEARWATER SPRINGS AL GR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:RODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-443-1818
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 1:201 NW 78TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-7904
Practice Address - Country:US
Practice Address - Phone:360-546-3344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA207240Medicaid