Healthcare Provider Details

I. General information

NPI: 1962493247
Provider Name (Legal Business Name): STAFFORD HEALTHCARE, SEATAC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 SOUTH 224TH ST
DES MOINES WA
98198-5132
US

IV. Provider business mailing address

2800 SOUTH 224TH ST
DES MOINES WA
96198-5132
US

V. Phone/Fax

Practice location:
  • Phone: 206-824-0600
  • Fax: 206-824-5622
Mailing address:
  • Phone: 206-824-0600
  • Fax: 206-824-5622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1364
License Number StateWA

VIII. Authorized Official

Name: MR. JAMES KENNETH BENNETT JR.
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential: MHA
Phone: 206-824-0600