MEDICARE: HOLIDAY LANE ESTATES ASSISTED LIVING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	117326	TX

General Provider Information

NPI Number	:	1396865317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLIDAY LANE ESTATES ASSISTED LIVING

Provider Business Mailing Address
First Line	:	3723 FAIRVIEW INDUSTRIAL DR SE STE 270
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-4975
Country	:	US
Telephone Number	:	503-485-4600
Fax Number	:

Provider Business Practice Location Address
First Line	:	6155 HOLIDAY LN
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-9332
Country	:	US
Telephone Number	:	817-427-0275
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JON HARDER
Credential	:
Telephone Number	:	503-485-4600

Provider Enumeration Date	:	03/31/2007
Last Update Date	:	08/22/2020

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