Provider Demographics
NPI:1134762230
Name:MT HOOD HOME CARE SERVICE LLC
Entity type:Organization
Organization Name:MT HOOD HOME CARE SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-826-8285
Mailing Address - Street 1:PO BOX 1478
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-1478
Mailing Address - Country:US
Mailing Address - Phone:503-826-8285
Mailing Address - Fax:503-668-9500
Practice Address - Street 1:459 SW MAPLE ROAD
Practice Address - Street 2:
Practice Address - City:ESTACADA
Practice Address - State:OR
Practice Address - Zip Code:97023
Practice Address - Country:US
Practice Address - Phone:503-826-8285
Practice Address - Fax:971-533-7952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-21
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500741303Medicaid