Provider Demographics
NPI:1205827037
Name:MARY'S WOODS AT MARYLHURST, INC
Entity Type:Organization
Organization Name:MARY'S WOODS AT MARYLHURST, INC
Other - Org Name:MARIE ROSE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:HOOD
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:503-675-2448
Mailing Address - Street 1:17400 HOLY NAMES DR
Mailing Address - Street 2:SUITE 70
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-5187
Mailing Address - Country:US
Mailing Address - Phone:503-675-2447
Mailing Address - Fax:503-675-2015
Practice Address - Street 1:17360 HOLY NAMES DR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-5137
Practice Address - Country:US
Practice Address - Phone:503-675-2475
Practice Address - Fax:503-675-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR310400000X, 311500000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR508756Medicaid
OR800046Medicaid
OR38-5265Medicare ID - Type Unspecified