Healthcare Provider Details

I. General information

NPI: 1073150074
Provider Name (Legal Business Name): CLAIR'S II ADULT FOSTER HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63249 EVEREST RD
COOS BAY OR
97420-7238
US

IV. Provider business mailing address

63249 EVEREST RD
COOS BAY OR
97420-7238
US

V. Phone/Fax

Practice location:
  • Phone: 541-269-7955
  • Fax: 541-269-7955
Mailing address:
  • Phone: 541-269-7955
  • Fax: 541-269-7955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State

VIII. Authorized Official

Name: MR. TIMOTHY JAMES BOYSUN I
Title or Position: PPO
Credential:
Phone: 541-269-7955