Provider Demographics
NPI:1629142294
Name:PUGET SOUND HEALTHCARE - OLYMPIA LLC
Entity Type:Organization
Organization Name:PUGET SOUND HEALTHCARE - OLYMPIA LLC
Other - Org Name:PUGET SOUND HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOV
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-678-4426
Mailing Address - Street 1:4001 CAPITOL MALL DRIVE SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8657
Mailing Address - Country:US
Mailing Address - Phone:360-754-9792
Mailing Address - Fax:360-754-2455
Practice Address - Street 1:4001 CAPITOL MALL DR SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8657
Practice Address - Country:US
Practice Address - Phone:360-754-9792
Practice Address - Fax:360-754-2455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4110102Medicaid
WA505299Medicare Oscar/Certification