1871774455 NPI number — MAPLE RIDGE RETIREMENT & ASSISTED LIVING COMMUNITY LLC

Table of content: (NPI 1871774455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871774455 NPI number — MAPLE RIDGE RETIREMENT & ASSISTED LIVING COMMUNITY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAPLE RIDGE RETIREMENT & ASSISTED LIVING COMMUNITY 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:
6
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:
1871774455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3220 STATE ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97301-6872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-373-3125
Provider Business Mailing Address Fax Number:
503-588-3531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1767 ALLIANCE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREELAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98249-9448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-331-1303
Provider Business Practice Location Address Fax Number:
360-331-1363
Provider Enumeration Date:
11/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HAMILTON
Authorized Official First Name:
KELLEY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO/PRESIDENT OF MANAGEMENT COMPANY
Authorized Official Telephone Number:
503-373-3125

Provider Taxonomy Codes

  • Taxonomy code: 305S00000X , with the licence number:  1966 , 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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