Provider Demographics
NPI:1447647482
Name:NORTH LAKE 5-O, LLC
Entity type:Organization
Organization Name:NORTH LAKE 5-O, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-899-5364
Mailing Address - Street 1:2818 NE 145TH ST
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-7556
Mailing Address - Country:US
Mailing Address - Phone:206-418-2900
Mailing Address - Fax:
Practice Address - Street 1:2818 NE 145TH ST
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-7556
Practice Address - Country:US
Practice Address - Phone:206-418-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1421314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA505262Medicare Oscar/Certification