Healthcare Provider Details

I. General information

NPI: 1164395638
Provider Name (Legal Business Name): DAYSTAR OLYMPIA ADULT FAMILY HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 ROCKCRESS DR SE
OLYMPIA WA
98513-2147
US

IV. Provider business mailing address

111 CANDLEWYCK DR W
LAKEWOOD WA
98499-8113
US

V. Phone/Fax

Practice location:
  • Phone: 978-885-7422
  • Fax:
Mailing address:
  • Phone: 978-885-7422
  • Fax: 253-352-8099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State

VIII. Authorized Official

Name: PERIS MBARIA
Title or Position: PROVIDER
Credential: RN
Phone: 978-996-0081