Provider Demographics
NPI:1386863769
Name:BD GRANTS PASS I LLC
Entity Type:Organization
Organization Name:BD GRANTS PASS I LLC
Other - Org Name:REGENCY CARE OF ROGUE VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEVORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-392-4066
Mailing Address - Street 1:3326 160TH AVE SE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-6418
Mailing Address - Country:US
Mailing Address - Phone:425-392-4066
Mailing Address - Fax:425-623-1517
Practice Address - Street 1:1710 NE FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-3877
Practice Address - Country:US
Practice Address - Phone:541-479-2606
Practice Address - Fax:541-471-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1648427843314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500620696Medicaid
OR800982Medicaid
OR500620696Medicaid