Healthcare Provider Details

I. General information

NPI: 1083128375
Provider Name (Legal Business Name): VERDANT GROVE ADULT FAMILY HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2017
Last Update Date: 11/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9644 54TH AVE S
SEATTLE WA
98118-5705
US

IV. Provider business mailing address

9650 54TH AVE S
SEATTLE WA
98118-5705
US

V. Phone/Fax

Practice location:
  • Phone: 206-722-2766
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number751083
License Number StateWA

VIII. Authorized Official

Name: LILIA PEROS SADUCOS
Title or Position: PROVIDER
Credential:
Phone: 206-694-3513