Provider Demographics
NPI:1164525077
Name:LAWRENCE CONVALESCENT CENTER
Entity Type:Organization
Organization Name:LAWRENCE CONVALESCENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:DOANE
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:BS HCA
Authorized Official - Phone:503-236-2624
Mailing Address - Street 1:812 SE 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1724
Mailing Address - Country:US
Mailing Address - Phone:503-236-2624
Mailing Address - Fax:503-233-9377
Practice Address - Street 1:812 SE 48TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1724
Practice Address - Country:US
Practice Address - Phone:503-236-2624
Practice Address - Fax:503-233-9377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR804724Medicaid