Provider Demographics
NPI:1306001474
Name:FOREST DRIVE OPERATIONS, LLC
Entity Type:Organization
Organization Name:FOREST DRIVE OPERATIONS, LLC
Other - Org Name:SUZANNE ELISE ASSISTED LIVING FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:RICKARD
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:503-570-3405
Mailing Address - Street 1:101 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138-7867
Mailing Address - Country:US
Mailing Address - Phone:503-738-0307
Mailing Address - Fax:503-717-8102
Practice Address - Street 1:101 FOREST DR
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138-7867
Practice Address - Country:US
Practice Address - Phone:503-738-0307
Practice Address - Fax:503-717-8102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1847571968310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR517786Medicaid