1770026361 NPI number — LIFESTREAM COMPLETE SENIOR LIVING, INC.

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 1770026361 NPI number — LIFESTREAM COMPLETE SENIOR LIVING, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFESTREAM COMPLETE SENIOR LIVING, 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:
LIFESTREAM AT YOUNGTOWN GREEN HOUSE 3
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:
1770026361
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11555 W. PEORIA AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YOUNGTOWN
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-933-3333
Provider Business Mailing Address Fax Number:
623-972-7320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11521 W. PEORIA AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YOUNGTOWN
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-972-2371
Provider Business Practice Location Address Fax Number:
623-972-7320
Provider Enumeration Date:
11/30/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT/COO
Authorized Official Telephone Number:
623-933-3333

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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