Healthcare Provider Details

I. General information

NPI: 1972483279
Provider Name (Legal Business Name): GLENHAVEN ADULT FAMILY HOME MARCIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2025
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 NW PARR DR
PULLMAN WA
99163-3686
US

IV. Provider business mailing address

PO BOX 1167
PULLMAN WA
99163-1167
US

V. Phone/Fax

Practice location:
  • Phone: 509-432-1169
  • Fax: 509-338-0595
Mailing address:
  • Phone: 509-432-1169
  • Fax: 509-338-0595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LORNA MILANOI SHOMPOLE
Title or Position: PROVIDER
Credential: CNA
Phone: 509-432-1169