Provider Demographics
NPI:1063591998
Name:WHIDBEY ISLAND MANOR, INC.
Entity type:Organization
Organization Name:WHIDBEY ISLAND MANOR, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:WIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-675-5913
Mailing Address - Street 1:PO BOX 1900
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-1900
Mailing Address - Country:US
Mailing Address - Phone:360-675-5913
Mailing Address - Fax:
Practice Address - Street 1:235 SW 6TH AVE
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-1900
Practice Address - Country:US
Practice Address - Phone:360-675-5913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4148102314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4148102Medicaid
WA4148102Medicaid