Healthcare Provider Details

I. General information

NPI: 1609129295
Provider Name (Legal Business Name): VIDELL HEALTHCARE PARK PLACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 04/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 CENTRAL AVE
HYDE PARK MA
02136-3021
US

IV. Provider business mailing address

16400 SOUTHCENTER PKWY SUITE 208
TUKWILA WA
98188-3335
US

V. Phone/Fax

Practice location:
  • Phone: 617-361-2388
  • Fax: 617-364-3112
Mailing address:
  • Phone: 253-277-3197
  • Fax: 206-299-3003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN J LAFORTE
Title or Position: MANAGER
Credential:
Phone: 253-277-3197