MEDICARE: PINE RIDGE MANAGEMENT WA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1588105308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE RIDGE MANAGEMENT WA LLC

Provider Business Mailing Address
First Line	:	200 CRESCENT CT STE 440
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75201-6964
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5615 WEST UMATILLA
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99206
Country	:	US
Telephone Number	:	509-924-4388
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	TRENT JOHNSON
Credential	:
Telephone Number	:	469-804-3716

Provider Enumeration Date	:	03/13/2017
Last Update Date	:	03/13/2017

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