Provider Demographics
NPI:1942220868
Name:RESIDENCE XII
Entity Type:Organization
Organization Name:RESIDENCE XII
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:KILWINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-823-8844
Mailing Address - Street 1:12029 113TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-6901
Mailing Address - Country:US
Mailing Address - Phone:425-823-8844
Mailing Address - Fax:425-820-2371
Practice Address - Street 1:12029 113TH AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-6901
Practice Address - Country:US
Practice Address - Phone:425-823-8844
Practice Address - Fax:425-820-2371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA17005200324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility