Basic Information
| Provider Information | |||||||||
| NPI: | 1063556504 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLOSSOM VALLEY WENATCHEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3006 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973020006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034854600 | ||||||||
| FaxNumber: | 5034851495 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 ORCHARD AVE | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988014702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096670990 | ||||||||
| FaxNumber: | 5034851495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARDER | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5034854600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | BH 1783 | WA | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.