1740312479 NPI number — WESLEY HOMES AT HOME, LLC

Table of content: (NPI 1740312479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740312479 NPI number — WESLEY HOMES AT HOME, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESLEY HOMES AT HOME, 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:
WESLEY HOMES COMMUNITY HEALTH SERVICES
Provider Other Organization Name Type Code:
5
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:
1740312479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
815 S 216TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98198-6332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-870-1127
Provider Business Mailing Address Fax Number:
206-870-1339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2111 N NORTHGATE WAY
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98133-9018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-870-1127
Provider Business Practice Location Address Fax Number:
206-870-1339
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MATTESON
Authorized Official First Name:
MARY
Authorized Official Middle Name:
KATHRYN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
206-870-1127

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  011286 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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