Provider Demographics
NPI:1093813214
Name:BD OLYMPIA I, LLC
Entity Type:Organization
Organization Name:BD OLYMPIA I, LLC
Other - Org Name:OLYMPIA MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-392-4066
Mailing Address - Street 1:3326 160TH AVE SE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-6418
Mailing Address - Country:US
Mailing Address - Phone:425-392-4066
Mailing Address - Fax:425-623-1517
Practice Address - Street 1:1811 22ND AVE SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-3023
Practice Address - Country:US
Practice Address - Phone:360-943-0910
Practice Address - Fax:360-753-8259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANH1179314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4111795Medicaid
WA4114237Medicaid
WA4114237Medicaid