1285837872 NPI number — PROVIDENCE MANOIR ASSISTED LIVING

Table of content: (NPI 1285837872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285837872 NPI number — PROVIDENCE MANOIR ASSISTED LIVING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE MANOIR ASSISTED LIVING
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285837872
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6567 S GARNET WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85249-7255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-388-1140
Provider Business Mailing Address Fax Number:
480-219-1889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6567 S GARNET WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85249-7255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-388-1140
Provider Business Practice Location Address Fax Number:
480-219-1889
Provider Enumeration Date:
06/09/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHARLES
Authorized Official First Name:
JEAN-MARIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF ADMISSIONS
Authorized Official Telephone Number:
480-388-1140

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  ALH-5829 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 162761 . This is a "ALTCS PROVIDER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".