Healthcare Provider Details

I. General information

NPI: 1255322087
Provider Name (Legal Business Name): ROYAL PLAZA RETIREMENT CENTER LEWISTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2870 JUNIPER DR
LEWISTON ID
83501-4720
US

IV. Provider business mailing address

2870 JUNIPER DR
LEWISTON ID
83501-4720
US

V. Phone/Fax

Practice location:
  • Phone: 208-746-2800
  • Fax: 208-746-0164
Mailing address:
  • Phone: 208-746-2800
  • Fax: 208-746-0164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number003266800
License Number StateID

VIII. Authorized Official

Name: MR. LARRY DEAN CHINN
Title or Position: MEMBER
Credential:
Phone: 360-794-9020