Provider Demographics
NPI:1730659228
Name:WAVERLY ASSISTED LIVING, LLC
Entity type:Organization
Organization Name:WAVERLY ASSISTED LIVING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BISTRONG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:971-280-0677
Mailing Address - Street 1:2853 SALEM AVE SE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321
Mailing Address - Country:US
Mailing Address - Phone:541-650-6200
Mailing Address - Fax:541-981-2211
Practice Address - Street 1:2853 SALEM AVE SE STE A
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321
Practice Address - Country:US
Practice Address - Phone:541-650-6200
Practice Address - Fax:541-981-2211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-28
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR38-7165OtherAGENCY LICENSE
OR500757550Medicaid