Basic Information
| Provider Information | |||||||||
| NPI: | 1356763130 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONSONUS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972224628 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972224628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2014 | ||||||||
| LastUpdateDate: | 01/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | MCKENZIE | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PTA | ||||||||
| AuthorizedOfficialTelephone: | 2084131771 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 08941 | OR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.