Basic Information
| Provider Information | |||||||||
| NPI: | 1972731677 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LSREF GOLDEN OPS VB (WA), LLC | ||||||||
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| OtherOrganizationName: | BLOSSOM VALLEY SENIOR ASSISTED LIVING COMMUNITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 STEVENS AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SOLANA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920752055 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 ORCHARD AVE | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988014702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096670990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2009 | ||||||||
| LastUpdateDate: | 07/01/2009 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | WICKLIFFE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8584367662 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 315300 | 05 | WA | MEDICAID |