Provider Demographics
NPI:1225445364
Name:SAPPHIRE AT GATEWAY LLC
Entity Type:Organization
Organization Name:SAPPHIRE AT GATEWAY LLC
Other - Org Name:GATEWAY CARE AND RETIREMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:RICKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-887-7395
Mailing Address - Street 1:127 NE 102ND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4152
Mailing Address - Country:US
Mailing Address - Phone:503-446-2877
Mailing Address - Fax:503-588-1023
Practice Address - Street 1:39 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4103
Practice Address - Country:US
Practice Address - Phone:503-252-2461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-22
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500680605Medicaid
OR500680605Medicaid