Provider Demographics
NPI:1750837597
Name:PROVIDENCE ELDERPLACE
Entity Type:Organization
Organization Name:PROVIDENCE ELDERPLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:LOMINGO
Authorized Official - Middle Name:M
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-546-9292
Mailing Address - Street 1:16430 NE HOYT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-5846
Mailing Address - Country:US
Mailing Address - Phone:503-875-5172
Mailing Address - Fax:
Practice Address - Street 1:16430 NE HOYT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230
Practice Address - Country:US
Practice Address - Phone:503-875-5172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH SYSTEMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201130602LPN310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility