1184619249 NPI number — COLONIAL VISTA CARE CENTERS, LLC

Table of content: (NPI 1184619249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184619249 NPI number — COLONIAL VISTA CARE CENTERS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLONIAL VISTA CARE CENTERS, 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:
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:
1184619249
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
681 OKANOGAN AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WENATCHEE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98801-3461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-663-8564
Provider Business Mailing Address Fax Number:
509-663-0461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 OKANOGAN AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WENATCHEE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-888-6090
Provider Business Practice Location Address Fax Number:
509-665-7388
Provider Enumeration Date:
09/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
NORMAN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
509-665-9462

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH1305 , 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: 4113056 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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