1093914004 NPI number — EVERGREEN AT MESA (ALF), L.L.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093914004 NPI number — EVERGREEN AT MESA (ALF), L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN AT MESA (ALF), L.L.C.
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:
MESA CHRISTIAN RESIDENTIAL CARE CENTER
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:
1093914004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 W BROWN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85201-3415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-668-6118
Provider Business Mailing Address Fax Number:
480-461-1552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 W BROWN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85201-3415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-668-6118
Provider Business Practice Location Address Fax Number:
480-461-1552
Provider Enumeration Date:
07/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NIPP
Authorized Official First Name:
ANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
360-892-6618

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  ALC-5063 , 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: 937427 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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