Healthcare Provider Details

I. General information

NPI: 1538842463
Provider Name (Legal Business Name): SOUTHWEST 2ND STREET HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SW 2ND ST
RENTON WA
98057-5937
US

IV. Provider business mailing address

15406 MERIDIAN E STE 201
PUYALLUP WA
98375-9504
US

V. Phone/Fax

Practice location:
  • Phone: 425-226-4610
  • Fax:
Mailing address:
  • Phone: 253-268-2410
  • 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: WILLIAM MILLER
Title or Position: CEO
Credential:
Phone: 253-268-2410