Healthcare Provider Details

I. General information

NPI: 1013629237
Provider Name (Legal Business Name): RESURRECTION ADULT FAMILY HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 NE 109TH AVE
VANCOUVER WA
98662-3371
US

IV. Provider business mailing address

10800 NE 109TH AVE
VANCOUVER WA
98662-3371
US

V. Phone/Fax

Practice location:
  • Phone: 360-258-0698
  • Fax:
Mailing address:
  • Phone: 360-258-0698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ABEBE GOBEZE
Title or Position: DIRECTOR
Credential:
Phone: 571-665-9250