Healthcare Provider Details

I. General information

NPI: 1497071286
Provider Name (Legal Business Name): CANTON SENIOR LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 04/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 RIVERSTONE TER
CANTON GA
30114-5218
US

IV. Provider business mailing address

3723 FAIRVIEW INDUSTRIAL DR SE
SALEM OR
97302-1177
US

V. Phone/Fax

Practice location:
  • Phone: 770-720-9669
  • Fax: 503-485-1279
Mailing address:
  • Phone: 503-485-8686
  • Fax: 503-485-1286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHIRLEY DUNN
Title or Position: CRO REPRESENTATIVE
Credential:
Phone: 503-485-4948