Provider Demographics
NPI:1679985113
Name:STATE OF OREGON DEPARTMENT OF VETERANS' AFFAIRS
Entity type:Organization
Organization Name:STATE OF OREGON DEPARTMENT OF VETERANS' AFFAIRS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-373-2268
Mailing Address - Street 1:600 N. 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355
Mailing Address - Country:US
Mailing Address - Phone:503-362-5235
Mailing Address - Fax:
Practice Address - Street 1:600 N. 5TH STREET
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355
Practice Address - Country:US
Practice Address - Phone:503-362-5235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500681197Medicaid
OR500681197Medicaid