Provider Demographics
NPI:1053609800
Name:NORTHWEST SNF LLC
Entity type:Organization
Organization Name:NORTHWEST SNF LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRETTON
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-991-1388
Mailing Address - Street 1:1701 PONTIAC RD
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4601 PALL MALL RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215
Practice Address - Country:US
Practice Address - Phone:410-664-5551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHOLLY OWNED BY WP NURSING PARENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-14
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility