Healthcare Provider Details

I. General information

NPI: 1629296231
Provider Name (Legal Business Name): MARIETTA SENIOR LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2007
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 POWDER SPRINGS RD SW
MARIETTA GA
30064-4154
US

IV. Provider business mailing address

PO BOX 3006
SALEM OR
97302-0006
US

V. Phone/Fax

Practice location:
  • Phone: 770-919-7799
  • Fax: 503-485-1279
Mailing address:
  • Phone: 503-485-8697
  • Fax: 503-486-1279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number033030251
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number033030251
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: JON M HARDER
Title or Position: MANAGER
Credential:
Phone: 503-375-9016