Provider Demographics
NPI:1760509558
Name:3723 FAIRVIEW INDUSTRIAL
Entity Type:Organization
Organization Name:3723 FAIRVIEW INDUSTRIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-485-4600
Mailing Address - Street 1:3723 FAIRVIEW INDUSTRIAL DR SE STE 270
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4975
Mailing Address - Country:US
Mailing Address - Phone:503-485-4600
Mailing Address - Fax:
Practice Address - Street 1:1770 NW VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1778
Practice Address - Country:US
Practice Address - Phone:541-673-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-25
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility