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General NPI Number Information
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NPI Number | 1184319063
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Entity Type | Organization
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Legal Business Name | LYDIE ADULT FAMILY HOME LLC
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Dates
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Enumeration Date | 04/06/2023
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Last Update Date | 04/06/2023
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Provider Practice Location Address
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Address Line | 11019 50TH AVE E
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City | TACOMA
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State | WA
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Zip | 98446-5303
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Country | US
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Telephone | 206-850-9109
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Fax |
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Provider Business Mailing Address
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Address Line | 16816 116TH AVENUE CT E
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City | PUYALLUP
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State | WA
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Zip | 98374-9119
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Country | US
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Telephone | 206-850-9109
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Fax |
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Authorized Official
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Title or Position | PROVIDER
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Name | JEAN SYLVAIN MISESO KABUYA
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Credential | RN
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Telephone | 206-850-9109
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number |
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License Number State |
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