Provider Demographics
NPI:1700078524
Name:WILKINSON GEORGIA IDAHO SENIOR HOUSING LLC
Entity Type:Organization
Organization Name:WILKINSON GEORGIA IDAHO SENIOR HOUSING LLC
Other - Org Name:FOUR SEASONS ASSITED LIVING
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-747-3373
Mailing Address - Street 1:78 CENTENNIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7900
Mailing Address - Country:US
Mailing Address - Phone:541-474-3373
Mailing Address - Fax:541-746-5781
Practice Address - Street 1:840 E DALTON AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9338
Practice Address - Country:US
Practice Address - Phone:208-665-2100
Practice Address - Fax:208-665-9250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service