1124064605 NPI number — AZORE II, LLC

Table of content: (NPI 1124064605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124064605 NPI number — AZORE II, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AZORE II, 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:
CHRIS RIDGE PREMIER CARE & REHABILITATION 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:
1124064605
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1077 GATEWAY LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97477-1114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-746-1020
Provider Business Mailing Address Fax Number:
541-284-7072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6246 N 19TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85015-1511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-433-6300
Provider Business Practice Location Address Fax Number:
602-433-6458
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GARBER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
541-746-1020

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NCI2661 , 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: 137010 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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