1174027114 NPI number — BFG KENNEWICK MASTER TENANT, LLC

Table of content: (NPI 1174027114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174027114 NPI number — BFG KENNEWICK MASTER TENANT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BFG KENNEWICK MASTER TENANT, 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:
FIELDSTONE MEMORY CARE OF KENNEWICK
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:
1174027114
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
228 N PARK AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32789-3886
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-644-6444
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
575 N YOUNG ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336-7806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-491-3945
Provider Business Practice Location Address Fax Number:
509-491-3948
Provider Enumeration Date:
03/23/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BOURNE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
INDIRECT MANAGER
Authorized Official Telephone Number:
407-644-6444

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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