Provider Demographics
NPI:1134163959
Name:NORTHWEST COUNTRY PLACE
Entity type:Organization
Organization Name:NORTHWEST COUNTRY PLACE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ODEGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-472-3141
Mailing Address - Street 1:421 SE EVANS ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6111
Mailing Address - Country:US
Mailing Address - Phone:503-472-3141
Mailing Address - Fax:503-472-9334
Practice Address - Street 1:421 S EVANS ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6111
Practice Address - Country:US
Practice Address - Phone:503-472-3141
Practice Address - Fax:503-472-9334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR800479Medicaid
OR800479Medicaid