Basic Information
Provider Information | |||||||||
NPI: | 1518245893 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAUREL COURT OF EUGENE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | QUAIL PARK MEMORY CARE RESIDENCES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1818 WESTLAKE AVE N STE 310 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981092707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2064411770 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2630 LONE OAK WAY | ||||||||
Address2: |   | ||||||||
City: | EUGENE | ||||||||
State: | OR | ||||||||
PostalCode: | 974042547 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5416075025 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/03/2011 | ||||||||
LastUpdateDate: | 08/03/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRYANT | ||||||||
AuthorizedOfficialFirstName: | DENIS | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
AuthorizedOfficialTelephone: | 2064411770 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | 1521694361 | OR | Y |   | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |   |
ID Information
ID | Type | State | Issuer | Description | 522713 | 05 | OR |   | MEDICAID |