1114262292 NPI number — BOULDER GARDENS ASSISTANT LIVING, LLC

Table of content: (NPI 1114262292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114262292 NPI number — BOULDER GARDENS ASSISTANT LIVING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOULDER GARDENS ASSISTANT LIVING, 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:
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:
1114262292
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 N LA CANADA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85614-3129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-352-3018
Provider Business Mailing Address Fax Number:
520-393-1044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
860 DOUGHERTY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86305-1841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-778-9667
Provider Business Practice Location Address Fax Number:
520-393-1044
Provider Enumeration Date:
11/30/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ZIMMERMAN
Authorized Official First Name:
CARL
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR VICE PRESIDENT
Authorized Official Telephone Number:
520-352-3019

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL1494C , 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: AL1494C . This is a "STATE LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".