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NPI Code Detail

MEDICARE: SOUTHBURY SENIOR LIVING, LLC

MEDICARE: SOUTHBURY SENIOR LIVING, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1310400000XAssisted Living Facility

General Provider Information

NPI Number : 1063626133
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHBURY SENIOR LIVING, LLC
Provider Business Mailing Address
First Line : PO BOX 3006
Second Line :
City : SALEM
State : OR
Zip : 97302-0006
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 655 MAIN ST S
Second Line :
City : SOUTHBURY
State : CT
Zip : 06488-4220
Country : US
Telephone Number : 503-485-4600
Fax Number :
Authorized Official
Title or Position : MANAGER
Name : JON HARDER
Credential :
Telephone Number : 503-485-4600
Provider Enumeration Date : 05/09/2007
Last Update Date : 08/22/2020

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Directions to “SOUTHBURY SENIOR LIVING, LLC ” Practice Location

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