Healthcare Provider Details

I. General information

NPI: 1003408212
Provider Name (Legal Business Name): WA3 OP RENTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SW 2ND ST
RENTON WA
98057-5937
US

IV. Provider business mailing address

80 SW 2ND ST
RENTON WA
98057-5937
US

V. Phone/Fax

Practice location:
  • Phone: 425-226-4610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SAMUEL GOLDNER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 516-727-1634