1780734509 NPI number — LAKELAND VILLAGE NURSING FACILITY

Table of content: (NPI 1780734509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780734509 NPI number — LAKELAND VILLAGE NURSING FACILITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKELAND VILLAGE NURSING FACILITY
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:
1780734509
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDICAL LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99022-0200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-299-1989
Provider Business Mailing Address Fax Number:
509-299-1070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
S 2320 SALNAVE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDICAL LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99022-0200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-299-1989
Provider Business Practice Location Address Fax Number:
509-299-1070
Provider Enumeration Date:
01/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KELLEN
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
EARL
Authorized Official Title or Position:
ASSISTANT SUPERINTENDENT
Authorized Official Telephone Number:
509-299-1989

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  00L020 , 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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