Provider Demographics
NPI:1376940809
Name:LEWISTON ROYAL PLAZA RETIREMENT, LLC
Entity Type:Organization
Organization Name:LEWISTON ROYAL PLAZA RETIREMENT, LLC
Other - Org Name:ROYAL PLAZA RETIREMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-892-6628
Mailing Address - Street 1:4601 NE 77TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6729
Mailing Address - Country:US
Mailing Address - Phone:360-892-6628
Mailing Address - Fax:360-882-5793
Practice Address - Street 1:2870 JUNIPER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4720
Practice Address - Country:US
Practice Address - Phone:208-746-2800
Practice Address - Fax:208-746-0164
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMPRES IDAHO HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRC-1083310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPENDINGMedicaid