Provider Demographics
NPI:1790160604
Name:400 29TH STREET NORTHEAST OPERATIONS LLC
Entity Type:Organization
Organization Name:400 29TH STREET NORTHEAST OPERATIONS LLC
Other - Org Name:LINDEN GROVE HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:400 29TH ST NE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-6774
Mailing Address - Country:US
Mailing Address - Phone:253-840-4400
Mailing Address - Fax:253-840-4411
Practice Address - Street 1:400 29TH ST NE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-6774
Practice Address - Country:US
Practice Address - Phone:253-840-4400
Practice Address - Fax:253-840-4411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0000314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility