Provider Demographics
NPI:1770392870
Name:AETERNUM CARE LLC
Entity type:Organization
Organization Name:AETERNUM CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:KISAMBIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-309-8976
Mailing Address - Street 1:613 SE 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-7311
Mailing Address - Country:US
Mailing Address - Phone:458-262-4514
Mailing Address - Fax:
Practice Address - Street 1:613 SE 32ND AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-7311
Practice Address - Country:US
Practice Address - Phone:458-262-4514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-03
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No174200000XOther Service ProvidersMeals
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility