Provider Demographics
NPI:1447405147
Name:PARKSIDE LIVING RTF
Entity Type:Organization
Organization Name:PARKSIDE LIVING RTF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:POONEH
Authorized Official - Middle Name:
Authorized Official - Last Name:ENTEZARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-309-6202
Mailing Address - Street 1:139 N LOTUS BEACH DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-8021
Mailing Address - Country:US
Mailing Address - Phone:503-309-6202
Mailing Address - Fax:
Practice Address - Street 1:1525 SW SHIRLEY ANN DR
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-7665
Practice Address - Country:US
Practice Address - Phone:503-472-9603
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness