Basic Information
| Provider Information | |||||||||
| NPI: | 1497071286 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANTON SENIOR LIVING, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TERRACE AT RIVERSTONE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3723 FAIRVIEW INDUSTRIAL DR SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973021177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034858686 | ||||||||
| FaxNumber: | 5034851286 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 RIVERSTONE TER | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301145218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707209669 | ||||||||
| FaxNumber: | 5034851279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2010 | ||||||||
| LastUpdateDate: | 04/19/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUNN | ||||||||
| AuthorizedOfficialFirstName: | SHIRLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CRO REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 5034854948 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.