Basic Information
| Provider Information | |||||||||
| NPI: | 1255322087 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROYAL PLAZA RETIREMENT CENTER LEWISTON, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2870 JUNIPER DR | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835014720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087462800 | ||||||||
| FaxNumber: | 2087460164 | ||||||||
| Practice Location | |||||||||
| Address1: | 2870 JUNIPER DR | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835014720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087462800 | ||||||||
| FaxNumber: | 2087460164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2005 | ||||||||
| LastUpdateDate: | 04/05/2012 | ||||||||
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| AuthorizedOfficialLastName: | CHINN | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | DEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3607949020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 003266800 | ID | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 003266800 | 05 | ID | MEDICAID |