Provider Demographics
NPI:1144267667
Name:TOUCHMARK AT FAIRWAY VILLAGE HOME HEALTH LLC
Entity type:Organization
Organization Name:TOUCHMARK AT FAIRWAY VILLAGE HOME HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:PRYOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-646-5186
Mailing Address - Street 1:5150 SW GRIFFITH DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2935
Mailing Address - Country:US
Mailing Address - Phone:503-646-5186
Mailing Address - Fax:503-644-3568
Practice Address - Street 1:2909 SE VILLAGE LOOP
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-8108
Practice Address - Country:US
Practice Address - Phone:360-254-2866
Practice Address - Fax:360-883-3103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA011429251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA50D1049339OtherCLIA LICENSE
WA50D1049339OtherCLIA LICENSE