Provider Demographics
NPI:1922352376
Name:SHANGRI-LA CORPORATION
Entity Type:Organization
Organization Name:SHANGRI-LA CORPORATION
Other - Org Name:VIA VERDE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:LENAY
Authorized Official - Last Name:WINKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-581-1732
Mailing Address - Street 1:4080 REED RD SE STE 150
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-1335
Mailing Address - Country:US
Mailing Address - Phone:503-581-1732
Mailing Address - Fax:503-316-2299
Practice Address - Street 1:4080 REED RD SE STE 150
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1335
Practice Address - Country:US
Practice Address - Phone:503-581-1732
Practice Address - Fax:503-316-2299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-07
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR516845OtherDMAP PROVIDER #