Provider Demographics
NPI:1659470193
Name:EAGLE HEALTHCARE, INC
Entity Type:Organization
Organization Name:EAGLE HEALTHCARE, INC
Other - Org Name:MENLO PARK HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-285-3891
Mailing Address - Street 1:12015 115TH AVE NE # E195
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-6940
Mailing Address - Country:US
Mailing Address - Phone:425-285-3891
Mailing Address - Fax:425-285-3899
Practice Address - Street 1:745 NE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2001
Practice Address - Country:US
Practice Address - Phone:503-252-0241
Practice Address - Fax:503-257-9091
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAGLE HEALTHCARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-21
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR800033Medicaid
OR385044Medicare Oscar/Certification