Basic Information
| Provider Information | |||||||||
| NPI: | 1760509558 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 3723 FAIRVIEW INDUSTRIAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3723 FAIRVIEW INDUSTRIAL DR SE STE 270 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973024975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034854600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1770 NW VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974701778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416733900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2007 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | HARDER | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5034854600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | OR | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.