Provider Demographics
NPI:1235355454
Name:WASHOUGAL ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:WASHOUGAL ASSISTED LIVING, LLC
Other - Org Name:COLUMBIA RIDGE ASSISTED LIVING, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-335-1238
Mailing Address - Street 1:4610 NE 77TH AVE
Mailing Address - Street 2:SUITE 132
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6789
Mailing Address - Country:US
Mailing Address - Phone:360-449-4524
Mailing Address - Fax:360-449-4525
Practice Address - Street 1:2300 W 9TH ST
Practice Address - Street 2:
Practice Address - City:WASHOUGAL
Practice Address - State:WA
Practice Address - Zip Code:98671-7437
Practice Address - Country:US
Practice Address - Phone:360-335-1238
Practice Address - Fax:360-833-0615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABH1521310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA465651Medicaid