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General NPI Number Information
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NPI Number | 1427649433
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Entity Type | Organization
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Legal Business Name | ANGEL VINE AFH LLC
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Dates
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Enumeration Date | 02/02/2021
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Last Update Date | 02/02/2021
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Provider Practice Location Address
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Address Line | 275 W VINE ST
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City | NAPAVINE
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State | WA
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Zip | 98532-7641
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Country | US
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Telephone | 360-262-3406
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Fax | 360-242-0125
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Provider Business Mailing Address
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Address Line | 199 SCHOOLHOUSE RD
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City | WINLOCK
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State | WA
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Zip | 98596-9718
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Country | US
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Telephone | 360-880-1751
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Fax | 360-242-0125
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Authorized Official
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Title or Position | OWNER/PARTNER
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Name | JOSHUA RUSSELL WACHTER
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Credential | RN
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Telephone | 360-880-1751
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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