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General NPI Number Information
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NPI Number | 1134520463
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Entity Type | Organization
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Legal Business Name | PROVIDENCE SENIOR HOME LLC
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Dates
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Enumeration Date | 09/05/2014
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Last Update Date | 09/05/2014
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Provider Practice Location Address
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Address Line | 3623 W INDIAN TRAIL RD
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City | SPOKANE
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State | WA
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Zip | 99208
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Country | US
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Telephone | 509-710-2776
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Fax |
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Provider Business Mailing Address
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Address Line | 3623 W INDIAN TRAIL RD
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City | SPOKANE
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State | WA
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Zip | 99208-4733
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Country | US
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Telephone | 509-638-8738
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Fax | 509-326-6468
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | MR. SANDU CODREANU
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Credential | NAC
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Telephone | 509-638-8738
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | A752165
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License Number State | WA
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