Provider Demographics
NPI:1881160182
Name:WOOD, PEARY
Entity type:Individual
Prefix:
First Name:PEARY
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 SW BARBUR BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5425
Mailing Address - Country:US
Mailing Address - Phone:503-719-5614
Mailing Address - Fax:503-477-9705
Practice Address - Street 1:2861 MOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-1539
Practice Address - Country:US
Practice Address - Phone:775-885-9223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR523037Medicaid
OR523038Medicaid
OR524973Medicaid