Provider Demographics
NPI:1558167841
Name:SH1 CEDAR CREST OPCO LLC
Entity type:Organization
Organization Name:SH1 CEDAR CREST OPCO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:564-203-3620
Mailing Address - Street 1:5101 NE 82ND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6343
Mailing Address - Country:US
Mailing Address - Phone:360-254-9442
Mailing Address - Fax:
Practice Address - Street 1:18325 SW PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-6966
Practice Address - Country:US
Practice Address - Phone:503-925-0544
Practice Address - Fax:503-625-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
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
OR515639Medicaid