Provider Demographics
NPI:1477309607
Name:SHALOM ADULT FAMILY HOME 1 LLC
Entity type:Organization
Organization Name:SHALOM ADULT FAMILY HOME 1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NANSUBUGA
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:206-501-0731
Mailing Address - Street 1:1102 S 72ND ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-3007
Mailing Address - Country:US
Mailing Address - Phone:253-301-1875
Mailing Address - Fax:253-301-1949
Practice Address - Street 1:1102 S 72ND ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-3007
Practice Address - Country:US
Practice Address - Phone:253-301-1875
Practice Address - Fax:253-301-1949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home