Provider Demographics
NPI:1588350466
Name:BONAVENTURE OF LACEY
Entity type:Organization
Organization Name:BONAVENTURE OF LACEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS RECEIVABLE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:JEANINE
Authorized Official - Last Name:LINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-371-3131
Mailing Address - Street 1:3425 BOONE RD SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-9336
Mailing Address - Country:US
Mailing Address - Phone:503-373-3131
Mailing Address - Fax:
Practice Address - Street 1:4528 INTELCO LOOP SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5916
Practice Address - Country:US
Practice Address - Phone:360-455-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)