Provider Demographics
NPI:1073774436
Name:SJV 1 EDMONDS OPCO LLC
Entity type:Organization
Organization Name:SJV 1 EDMONDS OPCO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR REIMBURSEMENT MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-854-0830
Mailing Address - Street 1:750 EDMONDS WAY
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-5126
Mailing Address - Country:US
Mailing Address - Phone:425-673-9700
Mailing Address - Fax:425-673-9701
Practice Address - Street 1:750 EDMONDS WAY
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-5126
Practice Address - Country:US
Practice Address - Phone:425-673-9700
Practice Address - Fax:425-673-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1740311500000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)