Basic Information
| Provider Information | |||||||||
| NPI: | 1114965894 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WATERFORD OPERATIONS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVAMERE AT THREE FOUNTAINS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25117 SW PARKWAY AVE | ||||||||
| Address2: | SUITE F | ||||||||
| City: | WILSONVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970709600 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 835 CRATER LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975046505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417737717 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 07/30/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | K. RICKARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5035703405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.