Basic Information
| Provider Information | |||||||||
| NPI: | 1962575191 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALDERCREST HEALTH - EDMONDS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALDERCREST HEALTH & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21400 72ND AVENUE WEST | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257741961 | ||||||||
| FaxNumber: | 4257710116 | ||||||||
| Practice Location | |||||||||
| Address1: | 21400 72ND AVE W | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257751961 | ||||||||
| FaxNumber: | 4257710116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 08/18/2017 | ||||||||
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| AuthorizedOfficialLastName: | JACOBS | ||||||||
| AuthorizedOfficialFirstName: | DOV | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3236784426 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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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 | 4194403 | 05 | WA | MEDICAID |