Basic Information
Provider Information | |||||||||
NPI: | 1932725967 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASHLAND ASSISTED LIVING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1701 S SUTRO TER | ||||||||
Address2: |   | ||||||||
City: | CARSON CITY | ||||||||
State: | NV | ||||||||
PostalCode: | 897060364 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7754686114 | ||||||||
FaxNumber: | 7755624757 | ||||||||
Practice Location | |||||||||
Address1: | 900 SKYLARK PL | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 975209640 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415521713 | ||||||||
FaxNumber: | 5415521058 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2020 | ||||||||
LastUpdateDate: | 06/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FISHER | ||||||||
AuthorizedOfficialFirstName: | DARRYL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7754686114 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X |   |   | N |   | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |   | 310400000X |   |   | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | 525976 | 05 | OR |   | MEDICAID | 525734 | 05 | OR |   | MEDICAID |