Provider Demographics
NPI:1407360936
Name:PONDEROSA RETIREMENT CENTER INC.
Entity Type:Organization
Organization Name:PONDEROSA RETIREMENT CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-453-1366
Mailing Address - Street 1:3300 ENGLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-1517
Mailing Address - Country:US
Mailing Address - Phone:509-453-1366
Mailing Address - Fax:509-452-4907
Practice Address - Street 1:3300 ENGLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-1517
Practice Address - Country:US
Practice Address - Phone:509-453-1366
Practice Address - Fax:509-452-4907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility