Provider Demographics
NPI:1962575191
Name:ALDERCREST HEALTH - EDMONDS LLC
Entity type:Organization
Organization Name:ALDERCREST HEALTH - EDMONDS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOV
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-678-4426
Mailing Address - Street 1:21400 72ND AVENUE WEST
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7702
Mailing Address - Country:US
Mailing Address - Phone:425-774-1961
Mailing Address - Fax:425-771-0116
Practice Address - Street 1:21400 72ND AVE W
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7702
Practice Address - Country:US
Practice Address - Phone:425-775-1961
Practice Address - Fax:425-771-0116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4194403Medicaid
WA505236Medicare Oscar/Certification