Provider Demographics
NPI:1508303793
Name:RENTON HEALTHCARE REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:RENTON HEALTHCARE REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ZACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-936-6000
Mailing Address - Street 1:230 N MARYLAND AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4281
Mailing Address - Country:US
Mailing Address - Phone:323-936-6000
Mailing Address - Fax:
Practice Address - Street 1:80 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5937
Practice Address - Country:US
Practice Address - Phone:425-226-4610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1554314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4113783Medicaid
WA4113783Medicaid