Basic Information
| Provider Information | |||||||||
| NPI: | 1316034473 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAGLE HEALTHCARE, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PARKSIDE NURSING CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12015 115TH AVE NE # E195 | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980346940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252853891 | ||||||||
| FaxNumber: | 4252853899 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 W EMMA ST | ||||||||
| Address2: | |||||||||
| City: | UNION GAP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989031940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092481985 | ||||||||
| FaxNumber: | 5092480681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 12/09/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHMIDT | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4252853891 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAGLE HEALTHCARE, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1310 | WA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4113106 | 05 | WA | MEDICAID |