Provider Demographics
NPI:1316045537
Name:BD TACOMA I, LLC
Entity Type:Organization
Organization Name:BD TACOMA I, LLC
Other - Org Name:PARK ROSE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FIELD ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-392-4066
Mailing Address - Street 1:3326 160TH AVE SE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-6418
Mailing Address - Country:US
Mailing Address - Phone:425-392-4066
Mailing Address - Fax:425-623-1517
Practice Address - Street 1:3919 S 19TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1414
Practice Address - Country:US
Practice Address - Phone:253-752-5677
Practice Address - Fax:253-756-8936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANH1298314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4112983Medicaid
WA4114245Medicaid
WA505239Medicare Oscar/Certification