Provider Demographics
NPI:1225898331
Name:2021 BOULEVARD COHOUSING LLC
Entity Type:Organization
Organization Name:2021 BOULEVARD COHOUSING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:IRWIN
Authorized Official - Last Name:STUSSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-259-5000
Mailing Address - Street 1:PO BOX 4008
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-0008
Mailing Address - Country:US
Mailing Address - Phone:360-259-5000
Mailing Address - Fax:360-357-7049
Practice Address - Street 1:2021 BOULEVARD RD SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-3227
Practice Address - Country:US
Practice Address - Phone:360-259-5000
Practice Address - Fax:360-357-7049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care