Organization
PACIFIC NORTHWEST LIVING LLC
Active
Other names
Pacific Northwest Living LLC
Organization subpart
No
Provider details
NPI number
Authorized official
ROSELLA MARY MILTIMORE OWNER/OPERATOR (EXECUTIVE DIRECTOR)
(503) 765-0454
Entity
Organization
Contact information
Practice address
4392 COLOMA DR SE, SALEM, OR 97302-5076
(971) 301-8831
(971) 301-8862
Mailing address
4392 COLOMA DR SE, SALEM, OR 97302-5076
(503) 765-0454
(971) 301-8862
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
DZ1463
AGENCY CERTIFICATE DEVELOPMENTAL DISABILITY
OR
05
—
DZ1463
—
OR
Enumeration date
01/08/2021
Last updated
01/08/2021
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