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General NPI Number Information
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NPI Number | 1669633707
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Entity Type | Organization
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Legal Business Name | JEFFERSON MANOR RESIDENTIAL CARE, LLC
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Dates
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Enumeration Date | 06/20/2008
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Last Update Date | 06/20/2008
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Provider Practice Location Address
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Address Line | 664 SE JEFFERSON ST
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City | DALLAS
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State | OR
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Zip | 97338-2024
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Country | US
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Telephone | 503-623-8104
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Fax | 503-623-0772
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Provider Business Mailing Address
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Address Line | 200 HAWTHORNE AVE SE STE A140
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City | SALEM
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State | OR
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Zip | 97301-5092
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Country | US
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Telephone | 503-588-2725
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Fax | 503-588-8653
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Authorized Official
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Title or Position | DIRECTOR OF RISK MANAGEMENT
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Name | ELIZABETH MARIE MOSS
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Credential |
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Telephone | 503-588-2725
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311500000X
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Taxonomy Name | Alzheimer Center (Dementia Center)
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License Number | 1087658107
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License Number State | OR
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