Provider Demographics
NPI:1700200011
Name:STONEWALL RESIDENTIAL CARE, LLC
Entity Type:Organization
Organization Name:STONEWALL RESIDENTIAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:BELLAR
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:509-413-9129
Mailing Address - Street 1:28921 N. RIVER ESTATES
Mailing Address - Street 2:
Mailing Address - City:CHATTAROY
Mailing Address - State:WA
Mailing Address - Zip Code:99003
Mailing Address - Country:US
Mailing Address - Phone:509-413-9129
Mailing Address - Fax:509-209-5684
Practice Address - Street 1:28921 N. RIVER ESTATES
Practice Address - Street 2:
Practice Address - City:CHATTAROY
Practice Address - State:WA
Practice Address - Zip Code:99003
Practice Address - Country:US
Practice Address - Phone:509-413-9129
Practice Address - Fax:509-209-5684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA751213320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities