Provider Demographics
NPI:1699760025
Name:PUYALLUP CARE CENTER, INC
Entity type:Organization
Organization Name:PUYALLUP CARE CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EX VP OF FINANCE / PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:VISLOCKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-735-7155
Mailing Address - Street 1:516 23RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-4659
Mailing Address - Country:US
Mailing Address - Phone:253-845-6631
Mailing Address - Fax:253-848-1357
Practice Address - Street 1:516 23RD AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-4659
Practice Address - Country:US
Practice Address - Phone:253-845-6631
Practice Address - Fax:253-848-1357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANH1376314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4113767Medicaid
WA4114344Medicaid
WA4113767Medicaid