Basic Information
| Provider Information | |||||||||
| NPI: | 1326273889 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINEHURST PARK ROYAL OPERATIONS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 116TH AVE SE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980046436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254514700 | ||||||||
| FaxNumber: | 4254536869 | ||||||||
| Practice Location | |||||||||
| Address1: | 2818 NE 145TH ST | ||||||||
| Address2: | |||||||||
| City: | SHORELINE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981557556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064182900 | ||||||||
| FaxNumber: | 2063653295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2009 | ||||||||
| LastUpdateDate: | 01/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | PRYDE | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | HARRY | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4254514700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4114211 | 05 | WA | MEDICAID |