1568699197 NPI number — LSREF GOLDEN OPS 26 (WA), LLC

Table of content: (NPI 1568699197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568699197 NPI number — LSREF GOLDEN OPS 26 (WA), LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LSREF GOLDEN OPS 26 (WA), LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ORCHARD POINTE SENIOR ALZHEIMER COMMUNITY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568699197
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 STEVENS AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SOLANA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92075-2055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 S KITSAP BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98366-3778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-874-7400
Provider Business Practice Location Address Fax Number:
360-874-1969
Provider Enumeration Date:
06/22/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PETERSON
Authorized Official First Name:
WICK
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT
Authorized Official Telephone Number:
858-775-5857

Provider Taxonomy Codes

  • Taxonomy code: 311500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 315196 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".