Provider Demographics
NPI:1619195229
Name:KENMORE SENIOR LIVING LLC
Entity Type:Organization
Organization Name:KENMORE SENIOR LIVING LLC
Other - Org Name:SPRING ESTATES SENIOR LIVING COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-375-9016
Mailing Address - Street 1:PO BOX 3006
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-0006
Mailing Address - Country:US
Mailing Address - Phone:503-375-9016
Mailing Address - Fax:503-485-1279
Practice Address - Street 1:7221 NE 182ND ST
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-2797
Practice Address - Country:US
Practice Address - Phone:425-481-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-22
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
WA1911310400000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)