Provider Demographics
NPI:1164844866
Name:PRAIRIE MANOR
Entity Type:Organization
Organization Name:PRAIRIE MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED OCCUPATIONAL THERAPY ASSI
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSEMARIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:COTA/L
Authorized Official - Phone:708-474-3116
Mailing Address - Street 1:25117 SW PARKWAY AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25117 SW PARKWAY AVE
Practice Address - Street 2:SUITE D
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9697
Practice Address - Country:US
Practice Address - Phone:708-754-7601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057001429314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility