Provider Demographics
NPI:1639296197
Name:PEDIATRIC INTERIM CARE CENTER, THE NEWBORN NURSERY
Entity Type:Organization
Organization Name:PEDIATRIC INTERIM CARE CENTER, THE NEWBORN NURSERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:DRENNEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-852-5253
Mailing Address - Street 1:328 4TH AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032
Mailing Address - Country:US
Mailing Address - Phone:253-852-5253
Mailing Address - Fax:253-852-5728
Practice Address - Street 1:328 4TH AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032
Practice Address - Country:US
Practice Address - Phone:253-852-5253
Practice Address - Fax:253-852-5728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6012505023140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7042823Medicaid