Provider Demographics
NPI:1205820669
Name:DELTA REHABILITATION CENTER
Entity type:Organization
Organization Name:DELTA REHABILITATION CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-568-2168
Mailing Address - Street 1:1705 TERRACE AVE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-1914
Mailing Address - Country:US
Mailing Address - Phone:360-568-2168
Mailing Address - Fax:360-568-5547
Practice Address - Street 1:1705 TERRACE AVE
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-1914
Practice Address - Country:US
Practice Address - Phone:360-568-2168
Practice Address - Fax:360-568-5547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
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
WA4154506Medicaid
WA4154506Medicaid