Provider Demographics
NPI:1730705823
Name:JENNINGS MCCALL CENTER
Entity type:Organization
Organization Name:JENNINGS MCCALL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GRAND SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMRAUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-357-3158
Mailing Address - Street 1:2221 OAK ST
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-2052
Mailing Address - Country:US
Mailing Address - Phone:503-359-4465
Mailing Address - Fax:503-359-8552
Practice Address - Street 1:2221 OAK ST
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2052
Practice Address - Country:US
Practice Address - Phone:503-359-4465
Practice Address - Fax:503-359-8552
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE MASONIC AND EASTERN STAR HOME OF OREGON, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR521693Medicaid
OR524956Medicaid