Provider Demographics
NPI:1356769293
Name:CRH PETERS CREEK LLC
Entity type:Organization
Organization Name:CRH PETERS CREEK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVOLACCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-317-9188
Mailing Address - Street 1:PO BOX 1410
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-1410
Mailing Address - Country:US
Mailing Address - Phone:541-317-9188
Mailing Address - Fax:541-389-3710
Practice Address - Street 1:14431 REDMOND WAY
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-4245
Practice Address - Country:US
Practice Address - Phone:425-869-2273
Practice Address - Fax:425-861-1876
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRH NORTHWEST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-28
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2245310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility