Healthcare Provider Details

I. General information

NPI: 1124959754
Provider Name (Legal Business Name): ABODE OF DELIGHT ADULT FAMILY HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30649 11TH AVE S
FEDERAL WAY WA
98003-4121
US

IV. Provider business mailing address

30649 11TH AVE S
FEDERAL WAY WA
98003-4121
US

V. Phone/Fax

Practice location:
  • Phone: 702-340-9857
  • Fax:
Mailing address:
  • Phone: 702-340-9857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MENGISTU SIMA
Title or Position: PROVIDER
Credential:
Phone: 702-340-9857