Provider Demographics
NPI:1649275140
Name:UNIVERSITY PLACE CARE CENTER
Entity type:Organization
Organization Name:UNIVERSITY PLACE CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:NOLA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIS-MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-566-7166
Mailing Address - Street 1:5520 BRIDGEPORT WAY W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98467-2041
Mailing Address - Country:US
Mailing Address - Phone:253-566-7166
Mailing Address - Fax:253-564-8034
Practice Address - Street 1:5520 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98467-2041
Practice Address - Country:US
Practice Address - Phone:253-566-7166
Practice Address - Fax:253-564-8034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANH 1098314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4110987Medicaid
WANH 1098Medicaid
WA50-5473Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER