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General NPI Number Information
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NPI Number | 1073745113
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Entity Type | Organization
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Legal Business Name | WILDERNESS SHORES NURSING, LLC
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Dates
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Enumeration Date | 08/21/2009
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Last Update Date | 08/21/2009
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Provider Practice Location Address
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Address Line | 25614 LAKE WILDERNESS LN SE
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City | MAPLE VALLEY
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State | WA
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Zip | 98038-6019
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Country | US
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Telephone | 206-931-5284
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Fax | 425-413-5116
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Provider Business Mailing Address
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Address Line | 25614 LAKE WILDERNESS LN SE
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City | MAPLE VALLEY
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State | WA
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Zip | 98038-6019
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Country | US
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Telephone | 206-931-5284
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Fax | 425-413-5116
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. SHIRLEY ANN MCMONAGLE
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Credential |
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Telephone | 206-931-5284
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | IHS.FS.60055610
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License Number State | WA
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