Healthcare Provider Details

I. General information

NPI: 1073774436
Provider Name (Legal Business Name): SJV 1 EDMONDS OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 EDMONDS WAY
EDMONDS WA
98020-5126
US

IV. Provider business mailing address

750 EDMONDS WAY
EDMONDS WA
98020-5126
US

V. Phone/Fax

Practice location:
  • Phone: 425-673-9700
  • Fax: 425-673-9701
Mailing address:
  • Phone: 425-673-9700
  • Fax: 425-673-9701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number1740
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number1740
License Number StateWA

VIII. Authorized Official

Name: MR. TONY J. HARRIS
Title or Position: SENIOR REIMBURSEMENT MANAGER
Credential:
Phone: 703-854-0830