Healthcare Provider Details

I. General information

NPI: 1376423624
Provider Name (Legal Business Name): MONMOUTH RESIDENTIAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2025
Last Update Date: 09/06/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

373 ATWATER ST S
MONMOUTH OR
97361-9705
US

IV. Provider business mailing address

373 ATWATER ST S
MONMOUTH OR
97361-9705
US

V. Phone/Fax

Practice location:
  • Phone: 971-381-0765
  • Fax: 503-837-0854
Mailing address:
  • Phone:
  • Fax: 503-837-0854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name: SAMUEL NGARUIYA
Title or Position: LICENSEE
Credential:
Phone: 971-381-0765