Provider Demographics
NPI:1598749038
Name:DALLAS MENNONITE RETIREMENT COMMUNITY, INC.
Entity Type:Organization
Organization Name:DALLAS MENNONITE RETIREMENT COMMUNITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CHAIR
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCMULLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-623-3843
Mailing Address - Street 1:377 NW JASPER ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1279
Mailing Address - Country:US
Mailing Address - Phone:503-623-5581
Mailing Address - Fax:503-623-2901
Practice Address - Street 1:377 NW JASPER ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1279
Practice Address - Country:US
Practice Address - Phone:503-623-5581
Practice Address - Fax:503-623-2901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR800268314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR800268Medicaid
OR385207Medicare ID - Type Unspecified