Provider Demographics
NPI:1982724100
Name:SOUTHPARK SENIOR LIVING LLC
Entity Type:Organization
Organization Name:SOUTHPARK SENIOR LIVING LLC
Other - Org Name:PLACE AT SOUTHPARK ASSISTED LIVING AND MEMORY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-375-9016
Mailing Address - Street 1:PO BOX 3006
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-0006
Mailing Address - Country:US
Mailing Address - Phone:503-375-9016
Mailing Address - Fax:
Practice Address - Street 1:2101 RUNNYMEDE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3316
Practice Address - Country:US
Practice Address - Phone:704-525-5508
Practice Address - Fax:704-525-2672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL060076310400000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805207Medicaid