Basic Information
| Provider Information | |||||||||
| NPI: | 1568871770 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KEIZER RIVER OPERATIONS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE ARBOR AT AVAMERE COURT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 450 CLAGETT CT. N | ||||||||
| Address2: | |||||||||
| City: | KEIZER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973034400 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 450 CLAGETT CT. N | ||||||||
| Address2: | |||||||||
| City: | KEIZER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973034400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035703405 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2014 | ||||||||
| LastUpdateDate: | 08/13/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | KARL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5035703405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.