Provider Demographics
NPI:1831274364
Name:STATE OF OREGON DEPARTMENT OF VETERANS AFFAIRS
Entity type:Organization
Organization Name:STATE OF OREGON DEPARTMENT OF VETERANS AFFAIRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DYKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-373-2387
Mailing Address - Street 1:700 SUMMER ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-1285
Mailing Address - Country:US
Mailing Address - Phone:503-373-2000
Mailing Address - Fax:503-373-2362
Practice Address - Street 1:700 VETERANS DR
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-9757
Practice Address - Country:US
Practice Address - Phone:541-296-7190
Practice Address - Fax:541-296-2339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR800072314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR800072Medicaid
OR73426380OtherOVH REGISTRY NUMBER
OR73426380OtherOVH REGISTRY NUMBER