1699289215 NPI number — DESERT SPRINGS CARE HOME L.L.C.

Table of content: (NPI 1699289215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699289215 NPI number — DESERT SPRINGS CARE HOME L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT SPRINGS CARE HOME L.L.C.
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:
1699289215
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3445 W ACOMA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85053-5620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-439-2734
Provider Business Mailing Address Fax Number:
602-843-1475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3445 W ACOMA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85053-5620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-439-2734
Provider Business Practice Location Address Fax Number:
602-843-1475
Provider Enumeration Date:
11/17/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MERTIC
Authorized Official First Name:
RODICA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/CAREGIVER
Authorized Official Telephone Number:
602-403-3624

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010117 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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