Provider Demographics
NPI:1699019711
Name:CARE CENTER COLVILLE INC.
Entity Type:Organization
Organization Name:CARE CENTER COLVILLE INC.
Other - Org Name:PRESTIGE CARE & REHABILITATION - PINEWOOD TERRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EX VP OF FINANCE / PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:VISLOCKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-735-7155
Mailing Address - Street 1:7700 NE PARKWAY DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6654
Mailing Address - Country:US
Mailing Address - Phone:360-735-7155
Mailing Address - Fax:360-735-9416
Practice Address - Street 1:1000 E ELEP AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-5014
Practice Address - Country:US
Practice Address - Phone:509-684-2573
Practice Address - Fax:509-685-2234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1303314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4114578Medicaid
WA4114578Medicaid