Provider Demographics
NPI:1891911145
Name:PROVIDENCE CITY, LLC
Entity Type:Organization
Organization Name:PROVIDENCE CITY, LLC
Other - Org Name:CACHE VALLEY 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:
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 1:233 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9622
Practice Address - Country:US
Practice Address - Phone:435-792-4770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility