Provider Demographics
NPI:1629372040
Name:TOUCHMARK AT MEADOW LAKE VILLAGE, LLC
Entity Type:Organization
Organization Name:TOUCHMARK AT MEADOW LAKE VILLAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:PRYOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-646-5186
Mailing Address - Street 1:5150 SW GRIFFITH DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2935
Mailing Address - Country:US
Mailing Address - Phone:503-646-5186
Mailing Address - Fax:503-644-3568
Practice Address - Street 1:625 S ARBOR LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3025
Practice Address - Country:US
Practice Address - Phone:208-884-3308
Practice Address - Fax:208-888-9381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHH160251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDHH160OtherSTATE LICENSURE
ID13D0947553OtherCLIA WAIVER
ID137092Medicare Oscar/Certification