Provider Demographics
NPI:1710681416
Name:ROZAH GROUP HOME LLC
Entity Type:Organization
Organization Name:ROZAH GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROZA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAKISSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-719-7667
Mailing Address - Street 1:15532 SE CLINTON CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-2125
Mailing Address - Country:US
Mailing Address - Phone:503-764-9803
Mailing Address - Fax:503-764-9807
Practice Address - Street 1:15532 SE CLINTON CT
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-2125
Practice Address - Country:US
Practice Address - Phone:503-764-9803
Practice Address - Fax:503-764-9807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities