1609171081 NPI number — MANOR CARE OF SALMON CREEK WA, ASSOCIATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609171081 NPI number — MANOR CARE OF SALMON CREEK WA, ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANOR CARE OF SALMON CREEK WA, ASSOCIATION
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:
PROMEDICA SKILLED NURSING AND REHABILITATION (SALMON CREEK)
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:
1609171081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 N SUMMIT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43604-2615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-252-5500
Provider Business Mailing Address Fax Number:
877-385-9446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2811 NE 139TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98686-2724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-574-5247
Provider Business Practice Location Address Fax Number:
360-574-9126
Provider Enumeration Date:
01/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
419-252-5734

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1609171081 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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