1629198858 NPI number — ACTIVE ASSISTED LIVING, LLC

Table of content: (NPI 1629198858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629198858 NPI number — ACTIVE ASSISTED LIVING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE ASSISTED LIVING, 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:
1629198858
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1235 S GILBERT RD
Provider Second Line Business Mailing Address:
STE 3, PMB 83
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85204-6005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-461-8272
Provider Business Mailing Address Fax Number:
480-461-4682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
758 S TOLTEC
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:
85204-3642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-461-8272
Provider Business Practice Location Address Fax Number:
480-461-4682
Provider Enumeration Date:
03/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THARALSON
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
480-461-8272

Provider Taxonomy Codes

  • Taxonomy code: 320700000X , with the licence number:  ALH-4567 , 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: ALH-4567 . This is a "ASSISTED LIVING LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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