Provider Demographics
NPI:1740312479
Name:WESLEY HOMES AT HOME, LLC
Entity type:Organization
Organization Name:WESLEY HOMES AT HOME, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHRYN
Authorized Official - Last Name:MATTESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-870-1127
Mailing Address - Street 1:815 S 216TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-6332
Mailing Address - Country:US
Mailing Address - Phone:206-870-1127
Mailing Address - Fax:206-870-1339
Practice Address - Street 1:2111 N NORTHGATE WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-9018
Practice Address - Country:US
Practice Address - Phone:206-870-1127
Practice Address - Fax:206-870-1339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA011286251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA507092Medicare PIN