Provider Demographics
NPI:1053023499
Name:ISSAQUAH OPERATIONS, LLC
Entity type:Organization
Organization Name:ISSAQUAH OPERATIONS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:KOFSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-224-2033
Mailing Address - Street 1:25115 SW PARKWAY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-8891
Mailing Address - Country:US
Mailing Address - Phone:503-830-8451
Mailing Address - Fax:
Practice Address - Street 1:805 FRONT ST S
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-4205
Practice Address - Country:US
Practice Address - Phone:425-392-1271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-16
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility