Provider Demographics
NPI:1154891224
Name:VINE MAPLE CARE HOME LLC
Entity type:Organization
Organization Name:VINE MAPLE CARE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LUZVIMINDA
Authorized Official - Middle Name:IMPERIAL
Authorized Official - Last Name:MONAGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:253-301-0099
Mailing Address - Street 1:12530 VINE MAPLE DR SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1134
Mailing Address - Country:US
Mailing Address - Phone:253-301-0099
Mailing Address - Fax:253-235-3645
Practice Address - Street 1:12530 VINE MAPLE DR SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1134
Practice Address - Country:US
Practice Address - Phone:253-301-0099
Practice Address - Fax:253-235-3645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2107449Medicaid