Provider Demographics
NPI:1528071206
Name:PRESBYTERIAN NURSING HOME
Entity type:Organization
Organization Name:PRESBYTERIAN NURSING HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXEC DIR ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:CATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:541-889-9133
Mailing Address - Street 1:1085 N OREGON ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-1549
Mailing Address - Country:US
Mailing Address - Phone:541-889-6157
Mailing Address - Fax:541-889-6148
Practice Address - Street 1:1085 N OREGON ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-1549
Practice Address - Country:US
Practice Address - Phone:541-889-6157
Practice Address - Fax:541-889-6148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OR007363336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR073874Medicaid
2078441OtherPK