Provider Demographics
NPI:1003879800
Name:BETHANY OF THE NORTHWEST
Entity Type:Organization
Organization Name:BETHANY OF THE NORTHWEST
Other - Org Name:BETHANY AT PACIFIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:SCRIVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-551-6400
Mailing Address - Street 1:PO BOX 13700
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98082-1700
Mailing Address - Country:US
Mailing Address - Phone:425-332-4475
Mailing Address - Fax:425-740-0426
Practice Address - Street 1:916 PACIFIC AVENUE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201
Practice Address - Country:US
Practice Address - Phone:425-259-5508
Practice Address - Fax:425-258-5656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA313007682314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4112900Medicaid
WA505404Medicare ID - Type UnspecifiedMEDICARE