1114143294 NPI number — GARDEN TERRACE, LLC

Table of content: (NPI 1114143294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114143294 NPI number — GARDEN TERRACE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARDEN TERRACE, 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:
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:
1114143294
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 S CHAPARRAL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIERRA VISTA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85635-4204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-459-0005
Provider Business Mailing Address Fax Number:
520-459-8461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 S CHAPARRAL CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIERRA VISTA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85635-4204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-459-0005
Provider Business Practice Location Address Fax Number:
520-459-8461
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PARROTTA
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR - OWNER
Authorized Official Telephone Number:
520-459-0005

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  ALH-5896 , 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: 164900 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com