Provider Demographics
NPI:1417957655
Name:MENNONITE HOME OF ALBANY, INC.
Entity Type:Organization
Organization Name:MENNONITE HOME OF ALBANY, INC.
Other - Org Name:LYDIA'S HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:W
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA, NHA
Authorized Official - Phone:541-928-7232
Mailing Address - Street 1:5353 COLUMBUS ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-7136
Mailing Address - Country:US
Mailing Address - Phone:541-928-7232
Mailing Address - Fax:541-917-1399
Practice Address - Street 1:5353 COLUMBUS ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-7136
Practice Address - Country:US
Practice Address - Phone:541-928-7232
Practice Address - Fax:541-917-1399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR504507Medicaid