Basic Information
| Provider Information | |||||||||
| NPI: | 1962493015 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAGLE HEALTHCARE, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | EAGLE REHABILITATION AT SUNNYSIDE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12015 115TH AVE NE # E195 | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980346940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252853891 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 721 OTIS AVE | ||||||||
| Address2: | |||||||||
| City: | SUNNYSIDE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989442328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098372122 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 06/21/2012 | ||||||||
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| AuthorizedOfficialLastName: | WONG | ||||||||
| AuthorizedOfficialFirstName: | CURRAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4252853886 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAGLE HEALTHCARE, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH1117 | WA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4111175 | 05 | WA | MEDICAID |