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General NPI Number Information
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NPI Number | 1891911145
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Entity Type | Organization
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Legal Business Name | PROVIDENCE CITY, LLC
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Dates
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Enumeration Date | 04/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 233 N MAIN ST
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City | PROVIDENCE
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State | UT
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Zip | 84332-9622
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Country | US
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Telephone | 435-792-4770
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Fax |
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Provider Business Mailing Address
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Address Line | 3723 FAIRVIEW INDUSTRIAL DR SE STE 270
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City | SALEM
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State | OR
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Zip | 97302-4975
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Country | US
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Telephone | 503-485-4600
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JON HARDER
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Credential |
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Telephone | 503-485-4600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State | UT
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