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General NPI Number Information
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NPI Number | 1356881866
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Entity Type | Organization
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Legal Business Name | WAVERLY ASSISTED LIVING, LLC
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Dates
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Enumeration Date | 03/02/2017
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Last Update Date | 08/06/2021
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Provider Practice Location Address
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Address Line | 2853 SALEM AVE SE
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City | ALBANY
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State | OR
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Zip | 97321-4562
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Country | US
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Telephone | 503-610-2932
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Fax |
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Provider Business Mailing Address
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Address Line | 2853 SALEM AVE SE STE A
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City | ALBANY
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State | OR
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Zip | 97321-4562
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Country | US
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Telephone | 971-204-7207
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Fax | 503-303-7234
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | KIM BISTRONG
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Credential | PT
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Telephone | 503-610-2932
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 13-1530
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License Number State | OR
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