1477697910 NPI number — PORT ORCHARD ALZHEIMERS CARE LLC

Table of content: (NPI 1477697910)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477697910 NPI number — PORT ORCHARD ALZHEIMERS CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORT ORCHARD ALZHEIMERS CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477697910
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3006
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97302-0006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-485-4600
Provider Business Mailing Address Fax Number:
503-485-1495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 S KITSAP BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98366-3778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-874-7400
Provider Business Practice Location Address Fax Number:
503-485-1495
Provider Enumeration Date:
02/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARDER
Authorized Official First Name:
JON
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO PRESIDENT
Authorized Official Telephone Number:
503-485-4600

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  BH 1785 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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