Provider Demographics
NPI:1922095934
Name:SISTERS OF ST. MARY OF OREGON MARYVILLE CORPORATION
Entity Type:Organization
Organization Name:SISTERS OF ST. MARY OF OREGON MARYVILLE CORPORATION
Other - Org Name:MARYVILLE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-643-8626
Mailing Address - Street 1:14645 SW FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-2727
Mailing Address - Country:US
Mailing Address - Phone:503-643-8626
Mailing Address - Fax:503-520-1435
Practice Address - Street 1:14645 SW FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-2727
Practice Address - Country:US
Practice Address - Phone:503-643-8626
Practice Address - Fax:503-520-1435
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SISTERS OF ST. MARY OF OREGON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-04
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00817314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00817Medicaid
OR385166Medicare Oscar/Certification