Provider Demographics
NPI:1407204746
Name:CREEKSIDE REHABILITATION AND NURSING
Entity Type:Organization
Organization Name:CREEKSIDE REHABILITATION AND NURSING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-709-4358
Mailing Address - Street 1:812 SE 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1724
Mailing Address - Country:US
Mailing Address - Phone:503-236-2624
Mailing Address - Fax:
Practice Address - Street 1:812 SE 48TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1724
Practice Address - Country:US
Practice Address - Phone:503-236-2624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-26
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR385277Medicare Oscar/Certification