Provider Demographics
NPI:1053459925
Name:TACOMA REHAB, LLC
Entity Type:Organization
Organization Name:TACOMA REHAB, LLC
Other - Org Name:AVAMERE AT PACIFIC RIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:503-570-3405
Mailing Address - Street 1:25117 SW PARKWAY AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3625 E B ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404-1524
Practice Address - Country:US
Practice Address - Phone:253-475-2507
Practice Address - Fax:253-473-9087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA505264Medicare Oscar/Certification
WA50-5264Medicare ID - Type Unspecified