Provider Demographics
NPI:1609129295
Name:VIDELL HEALTHCARE PARK PLACE, LLC
Entity Type:Organization
Organization Name:VIDELL HEALTHCARE PARK PLACE, LLC
Other - Org Name:PARK PLACE REHABILITATION AND SKILLED CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAFORTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-277-3197
Mailing Address - Street 1:16400 SOUTHCENTER PKWY
Mailing Address - Street 2:SUITE 208
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-3335
Mailing Address - Country:US
Mailing Address - Phone:253-277-3197
Mailing Address - Fax:206-299-3003
Practice Address - Street 1:113 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-3021
Practice Address - Country:US
Practice Address - Phone:617-361-2388
Practice Address - Fax:617-364-3112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
225375Medicare Oscar/Certification