Provider Demographics
NPI:1790829828
Name:VEGAS ASSISTED LIVING LLC
Entity type:Organization
Organization Name:VEGAS ASSISTED LIVING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:503-485-1279
Practice Address - Street 1:6031 CHEYENNE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-4200
Practice Address - Country:US
Practice Address - Phone:702-658-5882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2089AGC-21310400000X
NV2089AGC-16310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility