Provider Demographics
NPI:1720604499
Name:FM CEDAR VILLAGE, LLC
Entity Type:Organization
Organization Name:FM CEDAR VILLAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:RODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-443-1818
Mailing Address - Street 1:7420 SW BRIDGEPORT RD STE 105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7790
Mailing Address - Country:US
Mailing Address - Phone:503-597-4906
Mailing Address - Fax:503-443-1919
Practice Address - Street 1:4452 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1697
Practice Address - Country:US
Practice Address - Phone:503-390-9600
Practice Address - Fax:503-390-9152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR526908Medicaid
OR526907Medicaid