Basic Information
| Provider Information | |||||||||
| NPI: | 1528000387 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLAY & DAVIS MT BAKER DEVELOPMENT L L C | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MT BAKER CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2905 CONNELLY AVE | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982258225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607344181 | ||||||||
| FaxNumber: | 3606761669 | ||||||||
| Practice Location | |||||||||
| Address1: | 2905 CONNELLY AVE | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982258225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607344181 | ||||||||
| FaxNumber: | 3606761669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 05/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | CLAY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3607344181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 313M00000X | 1235 | WA | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 1235 | WA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4113338 | 05 | WA | MEDICAID | 505376A | 01 | MEDICARE | OTHER |