Basic Information
| Provider Information | |||||||||
| NPI: | 1699019711 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARE CENTER COLVILLE INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PRESTIGE CARE & REHABILITATION - PINEWOOD TERRACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7700 NE PARKWAY DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986626654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607357155 | ||||||||
| FaxNumber: | 3607359416 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E ELEP AVE | ||||||||
| Address2: | |||||||||
| City: | COLVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 991145014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096842573 | ||||||||
| FaxNumber: | 5096852234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 01/15/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VISLOCKY | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EX VP OF FINANCE / PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3607357155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1303 | WA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4114578 | 05 | WA | MEDICAID |