Provider Demographics
NPI:1164845921
Name:RUSSELLVILLE III LLC
Entity Type:Organization
Organization Name:RUSSELLVILLE III LLC
Other - Org Name:RUSSELLVILLE PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYN
Authorized Official - Middle Name:
Authorized Official - Last Name:RASAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-436-7827
Mailing Address - Street 1:23 SE 103RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216
Mailing Address - Country:US
Mailing Address - Phone:503-254-5900
Mailing Address - Fax:503-255-7098
Practice Address - Street 1:23 SE 103RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216
Practice Address - Country:US
Practice Address - Phone:503-254-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility