Basic Information
| Provider Information | |||||||||
| NPI: | 1578961413 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NECANICUM OPERATIONS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVAMERE AT SEASIDE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25117 SW PARKWAY AVE | ||||||||
| Address2: | SUITE F | ||||||||
| City: | WILSONVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970709697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035703405 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 S ROOSEVELT DR | ||||||||
| Address2: | |||||||||
| City: | SEASIDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971386366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037380900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2014 | ||||||||
| LastUpdateDate: | 12/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | KARL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5035703405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.