Provider Demographics
NPI:1205179256
Name:BLUE HERON SKILLED NURSING SERVICES
Entity Type:Organization
Organization Name:BLUE HERON SKILLED NURSING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GUNTHER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:360-774-1988
Mailing Address - Street 1:PO BOX 411
Mailing Address - Street 2:
Mailing Address - City:QUILCENE
Mailing Address - State:WA
Mailing Address - Zip Code:98376-0411
Mailing Address - Country:US
Mailing Address - Phone:360-301-0478
Mailing Address - Fax:360-765-3241
Practice Address - Street 1:165 MOON VALLEY DR
Practice Address - Street 2:
Practice Address - City:QUILCENE
Practice Address - State:WA
Practice Address - Zip Code:98376-0411
Practice Address - Country:US
Practice Address - Phone:360-301-0478
Practice Address - Fax:360-765-3241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-28
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00058765163W00000X, 163WC1500X, 163WH0200X
WARN00046933163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Multi-Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA322665OtherPROVIDER NUMBER