Provider Demographics
NPI:1285262147
Name:MG VENICE SUBTENANT LLC
Entity type:Organization
Organization Name:MG VENICE SUBTENANT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:SPEAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-676-5300
Mailing Address - Street 1:1938 FAIRVIEW AVE E STE 300
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3650
Mailing Address - Country:US
Mailing Address - Phone:206-676-5300
Mailing Address - Fax:206-676-5353
Practice Address - Street 1:1121 JACARANDA BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-4586
Practice Address - Country:US
Practice Address - Phone:941-497-1117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-27
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility