Basic Information
| Provider Information | |||||||||
| NPI: | 1497973002 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORTUNA ASSISTED LIVING LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SEQUOIA SPRINGS ASSISTED LIVING COMMUNITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3006 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973020006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034858697 | ||||||||
| FaxNumber: | 5034851279 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 REDWOOD WAY | ||||||||
| Address2: | |||||||||
| City: | FORTUNA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955403058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077260111 | ||||||||
| FaxNumber: | 5034851279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2007 | ||||||||
| LastUpdateDate: | 07/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | HARDER | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5033759016 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 126801582 | CA | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 311500000X | 126801852 | CA | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.