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General NPI Number Information
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NPI Number | 1710153937
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Entity Type | Organization
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Legal Business Name | ST NINO ADULT FAMILY HOME
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Dates
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Enumeration Date | 05/07/2008
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Last Update Date | 05/07/2008
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Provider Practice Location Address
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Address Line | 19620 8TH AVE E
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City | SPANAWAY
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State | WA
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Zip | 98387
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Country | US
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Telephone | 253-875-9077
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Fax | 253-875-9077
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Provider Business Mailing Address
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Address Line | 19620 8TH AVE E 19724 8TH AVE E SPANAWAY WA 98387
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City | SPANAWAY
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State | WA
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Zip | 98387-8478
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Country | US
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Telephone | 253-875-9077
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Fax |
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Authorized Official
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Title or Position | PROVIDER/OWNER
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Name | REZA S VARGAS
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Credential | NAR
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Telephone | 253-875-9077
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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 | 635100
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License Number State | WA
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