Healthcare Provider Details

I. General information

NPI: 1245228444
Provider Name (Legal Business Name): REVERA (DELAWARE) LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 05/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N. MEDCALF
MONTESANO WA
98563-1318
US

IV. Provider business mailing address

538 PRESTON AVE SUITE 270
MERIDEN CT
06450-4851
US

V. Phone/Fax

Practice location:
  • Phone: 360-249-2273
  • Fax: 360-249-2363
Mailing address:
  • Phone: 203-608-6100
  • Fax: 203-639-3574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number050005680
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1369
License Number StateWA

VIII. Authorized Official

Name: CAROLE M SCILLIA
Title or Position: LLC MANAGER
Credential:
Phone: 203-608-6100