Provider Demographics
NPI:1639169097
Name:WASHINGTON ODD FELLOWS HOME
Entity Type:Organization
Organization Name:WASHINGTON ODD FELLOWS HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRIGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-525-6463
Mailing Address - Street 1:534 BOYER AVENUE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362
Mailing Address - Country:US
Mailing Address - Phone:509-525-6463
Mailing Address - Fax:509-526-6883
Practice Address - Street 1:534 BOYER AVENUE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362
Practice Address - Country:US
Practice Address - Phone:509-525-6463
Practice Address - Fax:509-526-6883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANH351314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1015156Medicaid
WA4135109Medicaid
WA4135109Medicaid