Provider Demographics
NPI:1316932114
Name:RICHMOND BEACH REHAB LLC
Entity type:Organization
Organization Name:RICHMOND BEACH REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:KOFSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-224-2033
Mailing Address - Street 1:19235 15TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98177-2725
Mailing Address - Country:US
Mailing Address - Phone:206-546-2666
Mailing Address - Fax:206-542-1164
Practice Address - Street 1:19235 15TH AVE NW
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98177-2725
Practice Address - Country:US
Practice Address - Phone:206-546-2666
Practice Address - Fax:206-542-1164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-18
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4113460Medicaid
WA4113460Medicaid