Provider Demographics
NPI:1033535117
Name:GRAND PARK, LLC
Entity Type:Organization
Organization Name:GRAND PARK, LLC
Other - Org Name:CASCADE PARK ACTIVE DAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:253-627-9990
Mailing Address - Street 1:246 ST HELENS AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-2522
Mailing Address - Country:US
Mailing Address - Phone:253-627-9990
Mailing Address - Fax:253-680-1961
Practice Address - Street 1:246 ST HELENS AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-2522
Practice Address - Country:US
Practice Address - Phone:253-627-9990
Practice Address - Fax:253-680-1961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABH1251261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA570343Medicaid