1316125321 NPI number — CARE CENTER EDMONDS INC

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 1316125321 NPI number — CARE CENTER EDMONDS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARE CENTER EDMONDS INC
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:
PRESTIGE POST-ACUTE AND REHAB CENTER - EDMONDS
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:
1316125321
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7700 NE PARKWAY DR STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98662-6654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-735-7155
Provider Business Mailing Address Fax Number:
360-735-9416

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21008 76TH AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMONDS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98026-7104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-778-0107
Provider Business Practice Location Address Fax Number:
425-776-9532
Provider Enumeration Date:
02/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VISLOCKY
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
EVP OF FINANCE
Authorized Official Telephone Number:
360-735-7155

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: 4915281 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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