1528593944 NPI number — GROVES ASSISTED LIVING HOMES, LLC DBA PLUM TREE CARE HOME

Table of content: MAVEL DE LA CRUZ (NPI 1285464594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528593944 NPI number — GROVES ASSISTED LIVING HOMES, LLC DBA PLUM TREE CARE HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GROVES ASSISTED LIVING HOMES, LLC DBA PLUM TREE CARE HOME
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:
6
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:
1528593944
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7961 W SUNSET RANCH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85743-8203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-360-8090
Provider Business Mailing Address Fax Number:
520-325-9596

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4014 E PIMA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85712-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-867-6945
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WEEKS
Authorized Official First Name:
SHERRE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER/DIRECTOR
Authorized Official Telephone Number:
520-360-8090

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL9286H , 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: 884761 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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