Provider Demographics
NPI:1013679505
Name:A TULELAKE AFH LLC
Entity Type:Organization
Organization Name:A TULELAKE AFH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NGONYO
Authorized Official - Middle Name:
Authorized Official - Last Name:MWANGI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-533-3031
Mailing Address - Street 1:13211 TULE LAKE AVE S
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98444-2105
Mailing Address - Country:US
Mailing Address - Phone:253-533-3031
Mailing Address - Fax:
Practice Address - Street 1:13211 TULE LAKE AVE S
Practice Address - Street 2:
Practice Address - City:PARKLAND
Practice Address - State:WA
Practice Address - Zip Code:98444-2105
Practice Address - Country:US
Practice Address - Phone:253-533-3031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2170003Medicaid