Provider Demographics
NPI:1538425368
Name:QUAIL PARK OF KLAMATH FALLS, LLC
Entity type:Organization
Organization Name:QUAIL PARK OF KLAMATH FALLS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-441-1770
Mailing Address - Street 1:146 N CANAL ST
Mailing Address - Street 2:STE 220
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-8691
Mailing Address - Country:US
Mailing Address - Phone:206-441-1770
Mailing Address - Fax:206-441-1977
Practice Address - Street 1:1000 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-7137
Practice Address - Country:US
Practice Address - Phone:541-885-7250
Practice Address - Fax:541-882-8882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1090374171310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR523250Medicaid