1770577710 NPI number — AVALON CARE CENTER TUCSON LLC

Table of content: (NPI 1770577710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770577710 NPI number — AVALON CARE CENTER TUCSON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVALON CARE CENTER TUCSON 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:
1770577710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 N 2100 W
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84116-4740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-325-0153
Provider Business Mailing Address Fax Number:
801-596-9001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 E AJO WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85713-6211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-294-0005
Provider Business Practice Location Address Fax Number:
520-294-4417
Provider Enumeration Date:
09/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LINCOLN
Authorized Official First Name:
FAYE
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, POLICY/GOVERNMENT RELATIONS
Authorized Official Telephone Number:
801-325-0153

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NCI-2643 , 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: 835118 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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