Provider Demographics
NPI:1003214370
Name:ORDINARY LIFESTYLES, LLC
Entity Type:Organization
Organization Name:ORDINARY LIFESTYLES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-595-2068
Mailing Address - Street 1:401 N LAREDO LN
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-4389
Mailing Address - Country:US
Mailing Address - Phone:928-595-2068
Mailing Address - Fax:888-673-2528
Practice Address - Street 1:401 N LAREDO LN
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-4389
Practice Address - Country:US
Practice Address - Phone:928-595-2068
Practice Address - Fax:888-673-2528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL4632H311ZA0620X
AZAL9273H311ZA0620X
AZAL9118H311ZA0620X
AZAL9592H311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ854100OtherAHCCCS ID