Healthcare Provider Details

I. General information

NPI: 1386028397
Provider Name (Legal Business Name): 800 MEDCALF LANE NORTH OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2015
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N MEDCALF LN
MONTESANO WA
98563-1318
US

IV. Provider business mailing address

800 N MEDCALF LN
MONTESANO WA
98563-1318
US

V. Phone/Fax

Practice location:
  • Phone: 360-249-2273
  • Fax: 360-249-2363
Mailing address:
  • Phone: 360-249-2273
  • Fax: 360-249-2363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateWA

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4742