Provider Demographics
NPI:1912679168
Name:NORTHGLENN OPERATIONS, LLC
Entity Type:Organization
Organization Name:NORTHGLENN OPERATIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:ODERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-783-2489
Mailing Address - Street 1:25115 SW PARKWAY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-8891
Mailing Address - Country:US
Mailing Address - Phone:503-783-2489
Mailing Address - Fax:
Practice Address - Street 1:401 MALLEY DR
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80233-2024
Practice Address - Country:US
Practice Address - Phone:303-452-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01279700Medicaid