Provider Demographics
NPI:1245227131
Name:NORTHWEST COUNTRY PLACE, INC
Entity Type:Organization
Organization Name:NORTHWEST COUNTRY PLACE, INC
Other - Org Name:LIBERTY COUNTRY PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-736-9384
Mailing Address - Street 1:917 S SCHEUBER RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9027
Mailing Address - Country:US
Mailing Address - Phone:360-736-9384
Mailing Address - Fax:360-736-6284
Practice Address - Street 1:917 S SCHEUBER RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9027
Practice Address - Country:US
Practice Address - Phone:360-736-9384
Practice Address - Fax:360-736-6284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANH1138314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4111381Medicaid
WA4111381Medicaid