Healthcare Provider Details

I. General information

NPI: 1881426898
Provider Name (Legal Business Name): GOD-S-LAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2024
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 LEGION WAY SW
OLYMPIA WA
98501-1219
US

IV. Provider business mailing address

4570 AVERY LN SE STE C5114
LACEY WA
98503-5608
US

V. Phone/Fax

Practice location:
  • Phone: 360-870-7949
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. RAEANNA LEE CHREST
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 360-870-7949