1528239753 NPI number — MIRANDA CARE ADULT FAMILY HOME

Table of content: (NPI 1528239753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528239753 NPI number — MIRANDA CARE ADULT FAMILY HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIRANDA CARE ADULT FAMILY HOME
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:
Provider Other Organization Name Type Code:
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:
1528239753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 N 39TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98901-1222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-577-0423
Provider Business Mailing Address Fax Number:
509-577-0635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 N 39TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98901-1222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-577-0423
Provider Business Practice Location Address Fax Number:
509-577-0635
Provider Enumeration Date:
03/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
REESE
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
CHRISTINE
Authorized Official Title or Position:
REGISTERED NURSE OWNER
Authorized Official Telephone Number:
509-952-5564

Provider Taxonomy Codes

  • Taxonomy code: 311Z00000X , with the licence number:  A208501 , 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)

  • Identifier: 311ZA0620X . This is a "ADULT CARE HOME" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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