MEDICARE: MARIETTA 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
1	310400000X	Assisted Living Facility	033030251	GA
2	311500000X	Alzheimer Center (Dementia Center)	033030251	GA
3	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1629296231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIETTA 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	:	503-485-8697
Fax Number	:	503-486-1279

Provider Business Practice Location Address
First Line	:	1790 POWDER SPRINGS RD SW
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-4154
Country	:	US
Telephone Number	:	770-919-7799
Fax Number	:	503-485-1279

Authorized Official
Title or Position	:	MANAGER
Name	:	JON M HARDER
Credential	:
Telephone Number	:	503-375-9016

Provider Enumeration Date	:	04/22/2007
Last Update Date	:	07/23/2008

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