Provider Demographics
NPI:1558360024
Name:MANOR PARK HEALTHCARE LLC
Entity Type:Organization
Organization Name:MANOR PARK HEALTHCARE LLC
Other - Org Name:PARK MANOR REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:1710 PLAZA WAY
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4362
Mailing Address - Country:US
Mailing Address - Phone:509-529-4218
Mailing Address - Fax:509-522-1729
Practice Address - Street 1:1710 PLAZA WAY
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4362
Practice Address - Country:US
Practice Address - Phone:509-529-4218
Practice Address - Fax:509-522-1729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
313M00000X
WA1342314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4113429Medicaid
WA4113429Medicaid