Provider Demographics
NPI:1013291657
Name:STATESERV MEDICAL OF OREGON, LLC
Entity type:Organization
Organization Name:STATESERV MEDICAL OF OREGON, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:ROODE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-633-7250
Mailing Address - Street 1:1201 S. ALMA SCHOOL ROAD
Mailing Address - Street 2:SUITE 4000
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210
Mailing Address - Country:US
Mailing Address - Phone:336-227-8030
Mailing Address - Fax:336-227-3288
Practice Address - Street 1:26100 SW 95TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070
Practice Address - Country:US
Practice Address - Phone:503-729-2371
Practice Address - Fax:503-598-9737
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE STATESERV COMPANIES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-30
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORNPC-0003526332BX2000X
OR332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5619060001Medicare PIN