Organization
817 EAST PLUM STREET OPERATIONS LLC
Active
Other names
LAKE RIDGE CENTER
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL T BERG JD (ASST SECRETARY)
(505) 468-4742
Entity
Organization
Contact information
Practice address
817 E PLUM ST, MOSES LAKE, WA 98837-1870
(509) 765-7835
Mailing address
101 E STATE ST, KENNETT SQUARE, PA 19348-3109
(610) 444-6350
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
4114435
—
WA
01
—
505261
MEDICARE
—
Enumeration date
10/17/2022
Last updated
10/17/2022
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