Provider Demographics
NPI:1346288362
Name:LAURELHURST VILLAGE LLC
Entity Type:Organization
Organization Name:LAURELHURST VILLAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WALOROFF
Authorized Official - Suffix:
Authorized Official - Credentials:RN MS
Authorized Official - Phone:503-595-2810
Mailing Address - Street 1:3060 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3053
Mailing Address - Country:US
Mailing Address - Phone:503-535-4700
Mailing Address - Fax:503-797-6702
Practice Address - Street 1:3060 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3053
Practice Address - Country:US
Practice Address - Phone:503-535-4700
Practice Address - Fax:503-797-6702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR310400000X, 313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR800093Medicaid
OR385010Medicare ID - Type UnspecifiedCMS