Provider Demographics
NPI:1154371888
Name:TRINITY MISSION HEALTH & REHAB OF PORTLAND, LP
Entity type:Organization
Organization Name:TRINITY MISSION HEALTH & REHAB OF PORTLAND, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ULLERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-937-7994
Mailing Address - Street 1:10435 SE CORA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-2331
Mailing Address - Country:US
Mailing Address - Phone:503-760-1737
Mailing Address - Fax:503-761-1582
Practice Address - Street 1:10435 SE CORA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-2331
Practice Address - Country:US
Practice Address - Phone:503-760-1737
Practice Address - Fax:503-761-1582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORN/A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR800750Medicaid
OR38-5264Medicare ID - Type Unspecified