Provider Demographics
NPI:1669685939
Name:GRESHAM ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:GRESHAM ASSISTED LIVING LLC
Other - Org Name:HUNTINGTON TERRACE ASSISTED LIVING RESIDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO-PRES OF MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-566-5715
Mailing Address - Street 1:1410 NE CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-4283
Mailing Address - Country:US
Mailing Address - Phone:503-465-1404
Mailing Address - Fax:503-669-8896
Practice Address - Street 1:3220 STATE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-6872
Practice Address - Country:US
Practice Address - Phone:506-566-5715
Practice Address - Fax:503-588-3531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR704667-85OtherREGISTRY #