Basic Information
| Provider Information | |||||||||
| NPI: | 1528126091 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LONG TERM CARE DIVISION OF OCPHD 4 | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTH VALLEY EXTENDED CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 22 W 1ST ST | ||||||||
| Address2: | |||||||||
| City: | TONASKET | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988558846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094863152 | ||||||||
| FaxNumber: | 5094863116 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 W 1ST ST | ||||||||
| Address2: | |||||||||
| City: | TONASKET | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988558846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094863152 | ||||||||
| FaxNumber: | 5094863116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ULRICH | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5094863113 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | H-107 | WA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4210704 | 05 | WA | MEDICAID |