Provider Demographics
NPI:1497646939
Name:MOUNTLAKE TERRACE AFH 1 LLC
Entity type:Organization
Organization Name:MOUNTLAKE TERRACE AFH 1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TSEHAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GHEBRESILASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-330-3293
Mailing Address - Street 1:8907 192ND ST SW
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-6129
Mailing Address - Country:US
Mailing Address - Phone:206-330-3293
Mailing Address - Fax:
Practice Address - Street 1:23108 54TH AVE W
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-4708
Practice Address - Country:US
Practice Address - Phone:425-670-2867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-12
Last Update Date:2025-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility