Provider Demographics
NPI:1790909786
Name:REGENCY GRESHAM NURSING & REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:REGENCY GRESHAM NURSING & REHABILITATION CENTER LLC
Other - Org Name:REGENCY GRESHAM NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BEDDOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-392-4066
Mailing Address - Street 1:3326 160TH AVE SE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-6418
Mailing Address - Country:US
Mailing Address - Phone:425-392-4066
Mailing Address - Fax:425-623-1517
Practice Address - Street 1:5905 SE POWELL VALLEY RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-1919
Practice Address - Country:US
Practice Address - Phone:503-665-1151
Practice Address - Fax:503-669-1966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR808550314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR800117Medicaid
OR385015Medicare Oscar/Certification
OR800117Medicaid