Provider Demographics
NPI:1629224449
Name:VILLAGE HEALTH CARE I, LLC
Entity Type:Organization
Organization Name:VILLAGE HEALTH CARE I, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:JESSE
Authorized Official - Last Name:MARCOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-665-0183
Mailing Address - Street 1:3955 SE 182ND AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5036
Mailing Address - Country:US
Mailing Address - Phone:503-665-0183
Mailing Address - Fax:503-666-6609
Practice Address - Street 1:3955 SE 182ND AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5036
Practice Address - Country:US
Practice Address - Phone:503-665-0183
Practice Address - Fax:503-666-6609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1124599635314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR800120Medicaid
OR800120Medicaid