Provider Demographics
NPI:1730314626
Name:EXTENDED CARE PORTFOLIO MULTISTATE POOL TENANT, LLC
Entity Type:Organization
Organization Name:EXTENDED CARE PORTFOLIO MULTISTATE POOL TENANT, LLC
Other - Org Name:ENCORE SENIOR VILLAGE AT PARADISE VALLEY
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-905-3303
Mailing Address - Street 1:6400 SE LAKE RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2129
Mailing Address - Country:US
Mailing Address - Phone:503-905-3303
Mailing Address - Fax:
Practice Address - Street 1:16621 N 38TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2102
Practice Address - Country:US
Practice Address - Phone:602-787-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EXTENDED CARE PORTFOLIO TENANT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALC-6667310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ358816OtherARIZONA HEALTH CARE COST CONTAINMENT SYSTEM