Healthcare Provider Details

I. General information

NPI: 1962679175
Provider Name (Legal Business Name): SHERIDAN SENIOR LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 10/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 SUGARLAND DR
SHERIDAN WY
82801
US

IV. Provider business mailing address

3723 FAIRVIEW INDUSTRIAL DR SE
SALEM OR
97302
US

V. Phone/Fax

Practice location:
  • Phone: 307-674-5575
  • Fax: 503-485-1279
Mailing address:
  • Phone: 503-375-9016
  • Fax: 503-485-1279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number10235
License Number StateWY

VIII. Authorized Official

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