Provider Demographics
NPI:1962493247
Name:STAFFORD HEALTHCARE, SEATAC, LLC
Entity type:Organization
Organization Name:STAFFORD HEALTHCARE, SEATAC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MHA
Authorized Official - Phone:206-824-0600
Mailing Address - Street 1:2800 SOUTH 224TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:96198-5132
Mailing Address - Country:US
Mailing Address - Phone:206-824-0600
Mailing Address - Fax:206-824-5622
Practice Address - Street 1:2800 SOUTH 224TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-5132
Practice Address - Country:US
Practice Address - Phone:206-824-0600
Practice Address - Fax:206-824-5622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1364314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4113643Medicaid
WA4113613Medicaid
WA505513Medicare Oscar/Certification