Provider Demographics
NPI:1285631036
Name:MARYVILLE NURSING HOME
Entity Type:Organization
Organization Name:MARYVILLE NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-643-8626
Mailing Address - Street 1:14645 SW FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-2727
Mailing Address - Country:US
Mailing Address - Phone:503-643-8626
Mailing Address - Fax:503-520-1435
Practice Address - Street 1:14645 SW FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-2727
Practice Address - Country:US
Practice Address - Phone:503-643-8626
Practice Address - Fax:503-520-1435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR311500000X, 313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Not Answered313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR806745Medicaid
OR385166Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER