Provider Demographics
NPI:1578184206
Name:LOLLY ANGEL HOUSE AFH LLC
Entity Type:Organization
Organization Name:LOLLY ANGEL HOUSE AFH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:509-901-4666
Mailing Address - Street 1:5704 DOUGLAS DR
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-2732
Mailing Address - Country:US
Mailing Address - Phone:509-901-4666
Mailing Address - Fax:
Practice Address - Street 1:5704 DOUGLAS DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-2732
Practice Address - Country:US
Practice Address - Phone:509-901-4666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2154431Medicaid