Provider Demographics
NPI:1114917630
Name:WASHINGTON ODD FELLOWS HOME
Entity Type:Organization
Organization Name:WASHINGTON ODD FELLOWS HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRIGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-525-6463
Mailing Address - Street 1:534 BOYER AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2047
Mailing Address - Country:US
Mailing Address - Phone:509-525-6463
Mailing Address - Fax:509-522-0578
Practice Address - Street 1:534 BOYER AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2047
Practice Address - Country:US
Practice Address - Phone:509-525-6463
Practice Address - Fax:509-522-0578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABH125310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA129082Medicaid