1164631487 NPI number — EVELYN STANSBARGER

Table of content: (NPI 1164631487)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164631487 NPI number — EVELYN STANSBARGER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVELYN STANSBARGER
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:
1164631487
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:
6524 E ODESSA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85215-1060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-612-1955
Provider Business Mailing Address Fax Number:
480-924-3168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5632 E FAIRBROOK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85205-5571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-612-1955
Provider Business Practice Location Address Fax Number:
480-924-3168
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STANSBARGER
Authorized Official First Name:
EVELYN
Authorized Official Middle Name:
Authorized Official Title or Position:
SINGLE MEMBER
Authorized Official Telephone Number:
480-612-1955

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  ALH5964 , 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: ALH5964 . This is a "ASSISTED GROUP HOME" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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