Provider Demographics
NPI:1134520463
Name:PROVIDENCE SENIOR HOME LLC
Entity type:Organization
Organization Name:PROVIDENCE SENIOR HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:SANDU
Authorized Official - Middle Name:
Authorized Official - Last Name:CODREANU
Authorized Official - Suffix:
Authorized Official - Credentials:NAC
Authorized Official - Phone:509-638-8738
Mailing Address - Street 1:3623 W INDIAN TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-4733
Mailing Address - Country:US
Mailing Address - Phone:509-638-8738
Mailing Address - Fax:509-326-6468
Practice Address - Street 1:3623 W INDIAN TRAIL RD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208
Practice Address - Country:US
Practice Address - Phone:509-710-2776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA752165302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization