Healthcare Provider Details

I. General information

NPI: 1124653993
Provider Name (Legal Business Name): CONSUMER DIRECT CARE NETWORK WASHINGTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 WOODLAND SQUARE LOOP SE
LACEY WA
98503-1069
US

IV. Provider business mailing address

100 CONSUMER DIRECT WAY
MISSOULA MT
59808-5037
US

V. Phone/Fax

Practice location:
  • Phone: 866-438-8591
  • Fax:
Mailing address:
  • Phone: 406-532-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: BEN BLEDSOE
Title or Position: PRESIDENT/CEO
Credential:
Phone: 406-532-2001