Healthcare Provider Details

I. General information

NPI: 1588043020
Provider Name (Legal Business Name): INDEPENDENCE REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 109TH AVE NE
BELLEVUE WA
98004-4485
US

IV. Provider business mailing address

12123 NE 172ND PL M201
BOTHELL WA
98011-6409
US

V. Phone/Fax

Practice location:
  • Phone: 425-233-8766
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberLL60391131
License Number StateWA

VIII. Authorized Official

Name: CHAD FULLMER
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 801-426-4905