Provider Demographics
NPI:1255958120
Name:ELDERBERRY SQUARE COMMUNITY, LLC
Entity type:Organization
Organization Name:ELDERBERRY SQUARE COMMUNITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-826-5190
Mailing Address - Street 1:3321 OAK ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-9515
Mailing Address - Country:US
Mailing Address - Phone:541-475-2273
Mailing Address - Fax:
Practice Address - Street 1:3321 OAK ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-9515
Practice Address - Country:US
Practice Address - Phone:541-475-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR522211Medicaid
OR522229Medicaid