Basic Information
| Provider Information | |||||||||
| NPI: | 1306931944 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAGLE HEALTHCARE AT CAMAS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EAGLE REHABILITATION AT CAMAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 NE DALLAS ST | ||||||||
| Address2: | |||||||||
| City: | CAMAS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252853891 | ||||||||
| FaxNumber: | 4252853899 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 NE EVERETT | ||||||||
| Address2: | |||||||||
| City: | CAMAS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608345055 | ||||||||
| FaxNumber: | 3608340504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 08/08/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WONG | ||||||||
| AuthorizedOfficialFirstName: | CURRAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4252853886 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAGLE HEALTHCARE, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1159 | WA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4111597 | 05 | WA | MEDICAID |