Provider Demographics
NPI:1285871657
Name:FERN LIFE CENTER LLC
Entity type:Organization
Organization Name:FERN LIFE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:EWERS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:425-391-3376
Mailing Address - Street 1:710 5TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2823
Mailing Address - Country:US
Mailing Address - Phone:425-391-3376
Mailing Address - Fax:
Practice Address - Street 1:710 5TH AVE NW
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2823
Practice Address - Country:US
Practice Address - Phone:425-391-3376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006769163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8807245Medicare PIN