Basic Information
Provider Information | |||||||||
NPI: | 1669690244 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADDIE MEEDOM HOUSE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADDIE MEEDOM HOUSE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3723 FAIRVIEW INDUSTRIAL DR SE | ||||||||
Address2: | 270 | ||||||||
City: | SALEM | ||||||||
State: | OR | ||||||||
PostalCode: | 973021177 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034854600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1445 PARKWAY DR | ||||||||
Address2: |   | ||||||||
City: | CRESCENT CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 955318021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074643311 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARDER | ||||||||
AuthorizedOfficialFirstName: | JOH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5034854600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X |   | CA | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.