1093107054 NPI number — HOUSTON CREEK ASSISTED LIVING

Table of content: ERIN KATHLEEN KETTERMAN (NPI 1215408448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093107054 NPI number — HOUSTON CREEK ASSISTED LIVING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOUSTON CREEK ASSISTED LIVING
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:
1093107054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 S HOUSTON CREEK CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAR VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85541-2521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 S HOUSTON CREEK CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAR VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85541-2521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-951-2467
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MALUCCI
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
928-951-2467

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL8468H , 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: 555517 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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