Provider Demographics
NPI:1780764332
Name:TOUCHMARK AT FAIRWAY VILLAGE LLC
Entity type:Organization
Organization Name:TOUCHMARK AT FAIRWAY VILLAGE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:PRYOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-646-5186
Mailing Address - Street 1:5150 SW GRIFFITH DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2935
Mailing Address - Country:US
Mailing Address - Phone:503-646-5186
Mailing Address - Fax:503-644-3568
Practice Address - Street 1:2911 SE VILLAGE LOOP
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-8103
Practice Address - Country:US
Practice Address - Phone:360-253-3855
Practice Address - Fax:360-433-6567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA50-6605Medicare PIN