Provider Demographics
NPI:1205053600
Name:ST. JUDE OPERATING COMPANY, LLC
Entity type:Organization
Organization Name:ST. JUDE OPERATING COMPANY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELCHOR
Authorized Official - Middle Name:
Authorized Official - Last Name:BALAZS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-526-2230
Mailing Address - Street 1:6003 SE 136TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-4567
Mailing Address - Country:US
Mailing Address - Phone:503-761-1155
Mailing Address - Fax:503-761-1142
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:503-761-1142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1026862561313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR385281Medicare Oscar/Certification