Provider Demographics
NPI:1073150074
Name:CLAIR'S II ADULT FOSTER HOME LLC
Entity Type:Organization
Organization Name:CLAIR'S II ADULT FOSTER HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PPO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BOYSUN
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:541-269-7955
Mailing Address - Street 1:63249 EVEREST RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-7238
Mailing Address - Country:US
Mailing Address - Phone:541-269-7955
Mailing Address - Fax:541-269-7955
Practice Address - Street 1:63249 EVEREST RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-7238
Practice Address - Country:US
Practice Address - Phone:541-269-7955
Practice Address - Fax:541-269-7955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care HomeGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500697484Medicaid
OR525988OtherSTATE OF OREGON