Provider Demographics
NPI:1952667669
Name:FOSTER CREEK OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:FOSTER CREEK OPERATING COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER MANAGED, MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WALDROFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-706-0878
Mailing Address - Street 1:PO BOX 1980
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-0587
Mailing Address - Country:US
Mailing Address - Phone:503-701-1412
Mailing Address - Fax:
Practice Address - Street 1:6003 SE 136TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-4567
Practice Address - Country:US
Practice Address - Phone:503-761-1155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR38E126Medicaid