Provider Demographics
NPI:1861413452
Name:LEGACY VISITING NURSE ASSOCIATION
Entity type:Organization
Organization Name:LEGACY VISITING NURSE ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOOMIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-415-5730
Mailing Address - Street 1:PO BOX 4466
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4466
Mailing Address - Country:US
Mailing Address - Phone:503-413-3958
Mailing Address - Fax:503-413-3212
Practice Address - Street 1:6475 SW BORLAND RD STE J
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9708
Practice Address - Country:US
Practice Address - Phone:503-225-6372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA315D00000X, 251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR132238Medicaid
OR054643OtherREGENCE BLUE CROSS
OR132238Medicaid