Healthcare Provider Details

I. General information

NPI: 1811493364
Provider Name (Legal Business Name): 1015 NORTH GARRISON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 N GARRISON RD
VANCOUVER WA
98664-1313
US

IV. Provider business mailing address

1015 N GARRISON RD
VANCOUVER WA
98664-1313
US

V. Phone/Fax

Practice location:
  • Phone: 360-694-7501
  • Fax: 360-694-8148
Mailing address:
  • Phone: 360-694-7501
  • Fax: 360-694-8148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1572
License Number StateWA

VIII. Authorized Official

Name: YEHUDA SCHMUKLER
Title or Position: MANAGER
Credential:
Phone: 323-350-7772