Basic Information
| Provider Information | |||||||||
| NPI: | 1043257421 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BD MONROE I LLC | ||||||||
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| OtherOrganizationName: | REGENCY CARE CENTER AT MONROE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3326 160TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980086418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253924066 | ||||||||
| FaxNumber: | 4256231473 | ||||||||
| Practice Location | |||||||||
| Address1: | 1355 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982722022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607944011 | ||||||||
| FaxNumber: | 3608051724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 05/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | DEVORE | ||||||||
| AuthorizedOfficialFirstName: | DOUG | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4253924066 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 1135 | WA | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 1135 | WA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4113353 | 05 | WA | MEDICAID | 4114252 | 05 | WA | MEDICAID |