Provider Demographics
NPI:1114776879
Name:PACIFIC NORTHWEST CARE, LLC.
Entity type:Organization
Organization Name:PACIFIC NORTHWEST CARE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GOVERNOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:VANDERDOES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-710-7067
Mailing Address - Street 1:19689 7TH AVE NE # 339
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-8091
Mailing Address - Country:US
Mailing Address - Phone:360-710-7067
Mailing Address - Fax:
Practice Address - Street 1:29252 SCENIC DR NE
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-9327
Practice Address - Country:US
Practice Address - Phone:360-360-2350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-15
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty