Basic Information
| Provider Information | |||||||||
| NPI: | 1780759977 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEQUIM HEALTH, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SEQUIM HEALTH AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 W HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | SEQUIM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983823718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605822400 | ||||||||
| FaxNumber: | 3605822419 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 W HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | SEQUIM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983823718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605822400 | ||||||||
| FaxNumber: | 3605822419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | JACOBS | ||||||||
| AuthorizedOfficialFirstName: | DOV | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3236784426 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 4114120 | 05 | WA | MEDICAID |