Healthcare Provider Details

I. General information

NPI: 1639296197
Provider Name (Legal Business Name): PEDIATRIC INTERIM CARE CENTER, THE NEWBORN NURSERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 4TH AVENUE SOUTH
KENT WA
98032
US

IV. Provider business mailing address

328 4TH AVENUE SOUTH
KENT WA
98032
US

V. Phone/Fax

Practice location:
  • Phone: 253-852-5253
  • Fax: 253-852-5728
Mailing address:
  • Phone: 253-852-5253
  • Fax: 253-852-5728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number601250502
License Number StateWA

VIII. Authorized Official

Name: MRS. BARBARA DRENNEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 253-852-5253