1003201641 NPI number — WATERMARK CARLOTTA, LLC

Table of content: (NPI 1003201641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003201641 NPI number — WATERMARK CARLOTTA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WATERMARK CARLOTTA, LLC
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:
THE SPRINGS AT THE CARLOTTA
Provider Other Organization Name Type Code:
3
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:
1003201641
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 W RUDASILL RD
Provider Second Line Business Mailing Address:
ATTN: MEDICARE BILLING
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85704-7800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-797-4000
Provider Business Mailing Address Fax Number:
520-797-7757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41505 CARLOTTA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92211-3279
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-346-5420
Provider Business Practice Location Address Fax Number:
760-341-7768
Provider Enumeration Date:
03/31/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FRAZIER
Authorized Official First Name:
GRETA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
520-797-4000

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  250000099 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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