Provider Demographics
NPI:1568450807
Name:WESLEY HOMES DES MOINES LLC
Entity Type:Organization
Organization Name:WESLEY HOMES DES MOINES LLC
Other - Org Name:WESLEY HOMES HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CAMPUS ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-870-1300
Mailing Address - Street 1:1122 S 216TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-8301
Mailing Address - Country:US
Mailing Address - Phone:206-870-1345
Mailing Address - Fax:206-870-1321
Practice Address - Street 1:1122 S 216TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-8301
Practice Address - Country:US
Practice Address - Phone:206-870-1345
Practice Address - Fax:206-870-1321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4110961Medicaid
WA505475Medicare Oscar/Certification