Provider Demographics
NPI:1669633707
Name:JEFFERSON MANOR RESIDENTIAL CARE, LLC
Entity Type:Organization
Organization Name:JEFFERSON MANOR RESIDENTIAL CARE, LLC
Other - Org Name:JEFFERSON MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF RISK MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-588-2725
Mailing Address - Street 1:200 HAWTHORNE AVE SE STE A140
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-5092
Mailing Address - Country:US
Mailing Address - Phone:503-588-2725
Mailing Address - Fax:503-588-8653
Practice Address - Street 1:664 SE JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-2024
Practice Address - Country:US
Practice Address - Phone:503-623-8104
Practice Address - Fax:503-623-0772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1087658107311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR515448Medicaid