Provider Demographics
NPI:1316563042
Name:MEDFORD ASSISTED LIVING LLC
Entity type:Organization
Organization Name:MEDFORD ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:MONROE
Authorized Official - Last Name:WOOLLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-601-6070
Mailing Address - Street 1:1018 ROYAL CT
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6175
Mailing Address - Country:US
Mailing Address - Phone:541-773-2771
Mailing Address - Fax:541-776-5227
Practice Address - Street 1:1018 ROYAL CT
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6175
Practice Address - Country:US
Practice Address - Phone:541-773-2771
Practice Address - Fax:541-776-5227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR504356Medicaid