Healthcare Provider Details

I. General information

NPI: 1033535117
Provider Name (Legal Business Name): GRAND PARK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 ST HELENS AVE
TACOMA WA
98402-2522
US

IV. Provider business mailing address

246 ST HELENS AVE
TACOMA WA
98402-2522
US

V. Phone/Fax

Practice location:
  • Phone: 253-627-9990
  • Fax: 253-680-1961
Mailing address:
  • Phone: 253-627-9990
  • Fax: 253-680-1961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberBH1251
License Number StateWA

VIII. Authorized Official

Name: MRS. JANELLE RYAN
Title or Position: PROGRAM ADMINISTRATOR
Credential: MSW
Phone: 253-627-9990