Provider Demographics
NPI:1013629237
Name:RESURRECTION ADULT FAMILY HOME LLC
Entity Type:Organization
Organization Name:RESURRECTION ADULT FAMILY HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ABEBE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOBEZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-665-9250
Mailing Address - Street 1:10800 NE 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-3371
Mailing Address - Country:US
Mailing Address - Phone:360-258-0698
Mailing Address - Fax:
Practice Address - Street 1:10800 NE 109TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-3371
Practice Address - Country:US
Practice Address - Phone:360-258-0698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health