Basic Information
| Provider Information | |||||||||
| NPI: | 1013252618 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRILLIUM FAMILY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3415 SE POWELL BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972023371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032349591 | ||||||||
| FaxNumber: | 5032053554 | ||||||||
| Practice Location | |||||||||
| Address1: | 3415 SE POWELL BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972023371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032349591 | ||||||||
| FaxNumber: | 5032053554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2012 | ||||||||
| LastUpdateDate: | 12/07/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEDDLE | ||||||||
| AuthorizedOfficialFirstName: | CARLY | ||||||||
| AuthorizedOfficialMiddleName: | RAYE | ||||||||
| AuthorizedOfficialTitleorPosition: | REGISTERED NURSE | ||||||||
| AuthorizedOfficialTelephone: | 5035456284 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310500000X | 200840633RN | OR | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mental Illness |
No ID Information.