Provider Demographics
NPI:1225626765
Name:PACIFIC NORTHWEST LIVING LLC
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSELLA
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:MILTIMORE
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER/OPERATOR
Authorized Official - Phone:503-765-0454
Mailing Address - Street 1:4392 COLOMA DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5076
Mailing Address - Country:US
Mailing Address - Phone:503-765-0454
Mailing Address - Fax:971-301-8862
Practice Address - Street 1:4392 COLOMA DR SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5076
Practice Address - Country:US
Practice Address - Phone:971-301-8831
Practice Address - Fax:971-301-8862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDZ1463Medicaid
ORDZ1463OtherAGENCY CERTIFICATE DEVELOPMENTAL DISABILITY