Provider Demographics
NPI:1821084229
Name:LACEY NURSING CENTER, INC.
Entity Type:Organization
Organization Name:LACEY NURSING CENTER, INC.
Other - Org Name:ROO-LAN HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BURTON
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEVEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-491-1765
Mailing Address - Street 1:1505 CARPENTER RD SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-2906
Mailing Address - Country:US
Mailing Address - Phone:360-491-1765
Mailing Address - Fax:360-491-1891
Practice Address - Street 1:1505 CARPENTER RD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-2906
Practice Address - Country:US
Practice Address - Phone:360-491-1765
Practice Address - Fax:360-491-1891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4172904Medicaid
WA4172904Medicaid