Healthcare Provider Details

I. General information

NPI: 1477673473
Provider Name (Legal Business Name): PRAIRIE HOUSE ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51485 MORSON ST
LA PINE OR
97739-9481
US

IV. Provider business mailing address

3723 FAIRVIEW INDUSTRIAL DR SE STE 270
SALEM OR
97302-4975
US

V. Phone/Fax

Practice location:
  • Phone: 541-536-8559
  • Fax:
Mailing address:
  • Phone: 503-485-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateOR

VIII. Authorized Official

Name: JON HARDER
Title or Position: MANAGER
Credential:
Phone: 503-485-4600