Basic Information
| Provider Information | |||||||||
| NPI: | 1568088144 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RSL LA CONNER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10220 SW GREENBURG RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972235505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035952810 | ||||||||
| FaxNumber: | 5035952818 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 N. 1ST ST | ||||||||
| Address2: | |||||||||
| City: | LA CONNER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604665700 | ||||||||
| FaxNumber: | 3604662237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2020 | ||||||||
| LastUpdateDate: | 06/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | GUFFEE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT OF MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5035952810 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RADIANT COMPANIES, INC. | ||||||||
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| NPICertificationDate: | 06/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 2254 | 01 | WA | ASSISTED LIVING FACILITY LICENSE | OTHER | 111809501 | 05 | WA | MEDICAID |