Provider Demographics
NPI:1417221375
Name:CARROLLS GROUP CARE HOME INC
Entity Type:Organization
Organization Name:CARROLLS GROUP CARE HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:V
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-399-0189
Mailing Address - Street 1:PO BOX 12035
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-0035
Mailing Address - Country:US
Mailing Address - Phone:503-399-0189
Mailing Address - Fax:503-581-8799
Practice Address - Street 1:293 14TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4109
Practice Address - Country:US
Practice Address - Phone:503-399-0189
Practice Address - Fax:503-581-8799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR508201320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness