Basic Information
| Provider Information | |||||||||
| NPI: | 1063908556 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOSES LAKE OPERATIONS LLC | ||||||||
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| OtherOrganizationName: | AVAMERE AT MOSES LAKE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25117 SW PARKWAY AVE STE F | ||||||||
| Address2: | |||||||||
| City: | WILSONVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970709697 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8425 ASPI BLVD | ||||||||
| Address2: | |||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988373615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097629115 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2018 | ||||||||
| LastUpdateDate: | 07/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARALEGAL | ||||||||
| AuthorizedOfficialTelephone: | 5035703405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.