Provider Demographics
NPI:1306017124
Name:BLUEBERRY HILLS ADULT FAMILY HOME
Entity Type:Organization
Organization Name:BLUEBERRY HILLS ADULT FAMILY HOME
Other - Org Name:GRACE LAND ADULT FAMILY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FE
Authorized Official - Middle Name:PANGAN
Authorized Official - Last Name:CAVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-687-4433
Mailing Address - Street 1:20613 NE 176TH AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-3608
Mailing Address - Country:US
Mailing Address - Phone:360-687-4433
Mailing Address - Fax:360-687-9113
Practice Address - Street 1:20613 NE 176TH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-3608
Practice Address - Country:US
Practice Address - Phone:360-687-4433
Practice Address - Fax:360-687-9113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home