MEDICARE: 1405 S. MONROE STREET OPERATIONS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0000	OTHER	WA	LICENSE

General Provider Information

NPI Number	:	1578127213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1405 S. MONROE STREET OPERATIONS LLC

Provider Business Mailing Address
First Line	:	101 E STATE ST
Second Line	:
City	:	KENNETT SQUARE
State	:	PA
Zip	:	19348-3109
Country	:	US
Telephone Number	:	610-444-6350
Fax Number	:

Provider Business Practice Location Address
First Line	:	1405 S MONROE ST
Second Line	:
City	:	MOSES LAKE
State	:	WA
Zip	:	98837-4628
Country	:	US
Telephone Number	:	509-765-2200
Fax Number	:	509-765-2201

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MICHAEL T BERG
Credential	:
Telephone Number	:	505-468-4742

Provider Enumeration Date	:	04/29/2019
Last Update Date	:	04/29/2019

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