Provider Demographics
NPI:1801517842
Name:MOUNTAIN PALMS MANOR ADULT FAMILY HOME LLC
Entity type:Organization
Organization Name:MOUNTAIN PALMS MANOR ADULT FAMILY HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KINYUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-661-0208
Mailing Address - Street 1:5120 84TH AVE W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98467-1826
Mailing Address - Country:US
Mailing Address - Phone:803-661-0208
Mailing Address - Fax:253-240-1976
Practice Address - Street 1:5120 84TH AVE W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98467-1826
Practice Address - Country:US
Practice Address - Phone:803-661-0208
Practice Address - Fax:253-240-1976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home