Provider Demographics
NPI:1841692969
Name:BANDON SENIOR LIVING LLC
Entity type:Organization
Organization Name:BANDON SENIOR LIVING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:W
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-675-3925
Mailing Address - Street 1:1000 6TH AVE WEST
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411
Mailing Address - Country:US
Mailing Address - Phone:541-347-7502
Mailing Address - Fax:541-347-7802
Practice Address - Street 1:1000 6TH AVE WEST
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411
Practice Address - Country:US
Practice Address - Phone:541-347-7502
Practice Address - Fax:541-347-7802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1666408716310400000X
OR1493461250310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility