1386635134 NPI number — TEMPE LIFE CARE VILLAGE INC

Table of content: (NPI 1386635134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386635134 NPI number — TEMPE LIFE CARE VILLAGE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEMPE LIFE CARE VILLAGE INC
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:
FRIENDSHIP VILLAGE OF TEMPE
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:
1386635134
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2645 E SOUTHERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMPE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85282-7649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-831-0880
Provider Business Mailing Address Fax Number:
480-831-3259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 E SOUTHERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85282-7741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-831-3184
Provider Business Practice Location Address Fax Number:
480-831-3259
Provider Enumeration Date:
11/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CASSANO
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
480-560-3688

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  ALC4366 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 311500000X , with the licence number: ALC4711 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: NCI2646 , 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)





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