MEDICARE: PUGET SOUND HEALTHCARE - OLYMPIA 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	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629142294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUGET SOUND HEALTHCARE - OLYMPIA LLC

Provider Business Mailing Address
First Line	:	4001 CAPITOL MALL DRIVE SW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-8657
Country	:	US
Telephone Number	:	360-754-9792
Fax Number	:	360-754-2455

Provider Business Practice Location Address
First Line	:	4001 CAPITOL MALL DR SW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-8657
Country	:	US
Telephone Number	:	360-754-9792
Fax Number	:	360-754-2455

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. DOV E. JACOBS
Credential	:
Telephone Number	:	323-678-4426

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	08/18/2017

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