Healthcare Provider Details

I. General information

NPI: 1366656472
Provider Name (Legal Business Name): BREA EMERITUS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 ELLIOTT AVE 500
SEATTLE WA
98121-1044
US

IV. Provider business mailing address

3131 ELLIOTT AVE 500
SEATTLE WA
98121-1044
US

V. Phone/Fax

Practice location:
  • Phone: 206-289-2909
  • Fax:
Mailing address:
  • Phone: 206-289-2909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberAL0231
License Number StateCO

VIII. Authorized Official

Name: MR. KACY KANG
Title or Position: VICE PRESIDENT OPERATIONS
Credential: V.P.O.
Phone: 206-289-2909