Basic Information
Provider Information | |||||||||
NPI: | 1124236591 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ESC IV, L.P. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EMERITUS AT QUAIL RIDGE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3131 ELLIOTT AVE | ||||||||
Address2: | SUITE 500 | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981211044 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2062982909 | ||||||||
FaxNumber: | 2063014500 | ||||||||
Practice Location | |||||||||
Address1: | 5204 ELGIN AVE | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794134420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8067881919 | ||||||||
FaxNumber: | 8067857088 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2007 | ||||||||
LastUpdateDate: | 01/15/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BICKEL | ||||||||
AuthorizedOfficialFirstName: | NOELLE | ||||||||
AuthorizedOfficialMiddleName: | DIAZ | ||||||||
AuthorizedOfficialTitleorPosition: | LICENSING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 2062982909 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | EMERITUS PROPERTIES IV, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | 030161 | TX | Y |   | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |   |
No ID Information.