Healthcare Provider Details

I. General information

NPI: 1477784809
Provider Name (Legal Business Name): FRIENDS OF ROSE HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2009
Last Update Date: 08/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 YAKIMA AVE
TACOMA WA
98405-4458
US

IV. Provider business mailing address

1419 YAKIMA AVE
TACOMA WA
98405-4458
US

V. Phone/Fax

Practice location:
  • Phone: 253-272-1759
  • Fax: 253-627-1784
Mailing address:
  • Phone: 253-272-1759
  • Fax: 253-627-1784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number602412772
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number602412772
License Number StateWA

VIII. Authorized Official

Name: MR. KENNETH GIBSON
Title or Position: EXECUTIVE DIRECTOR
Credential: MNPL
Phone: 253-272-1759