Basic Information
Provider Information | |||||||||
NPI: | 1285751081 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SEASIDE SENIOR LIVING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NECANICUM VILLAGE ASSISTED LIVING & MEMORY CARE COMMUNITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3006 | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | OR | ||||||||
PostalCode: | 973020006 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5033759016 | ||||||||
FaxNumber: | 5034851279 | ||||||||
Practice Location | |||||||||
Address1: | 2500 SOUTH ROOSEVELT DR | ||||||||
Address2: |   | ||||||||
City: | SEASIDE | ||||||||
State: | OR | ||||||||
PostalCode: | 971386366 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5037380900 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/25/2007 | ||||||||
LastUpdateDate: | 07/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARDER | ||||||||
AuthorizedOfficialFirstName: | JON | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5034854600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 1401008247 | OR | N |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   | 311500000X | 1701870142 | OR | N |   | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |   | 310400000X |   | OR | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.