Provider Demographics
NPI:1407029978
Name:DAVID W AGNOR PHD PC
Entity Type:Organization
Organization Name:DAVID W AGNOR PHD PC
Other - Org Name:SENIOR CONNECTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:AGNOR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:360-253-4912
Mailing Address - Street 1:9340 NE 76TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-3721
Mailing Address - Country:US
Mailing Address - Phone:360-253-4912
Mailing Address - Fax:360-235-5170
Practice Address - Street 1:9340 NE 76TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-3721
Practice Address - Country:US
Practice Address - Phone:360-253-4912
Practice Address - Fax:360-253-5170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001983314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7089816Medicaid
WA7089816Medicaid