Provider Demographics
NPI:1013009745
Name:STATE OF ARIZONA STATE DEPT OF FINANCE
Entity Type:Organization
Organization Name:STATE OF ARIZONA STATE DEPT OF FINANCE
Other - Org Name:ARIZONA STATE VETERANS' HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-248-1591
Mailing Address - Street 1:4141 NORTH S. HERRERA WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012
Mailing Address - Country:US
Mailing Address - Phone:602-512-2955
Mailing Address - Fax:602-265-3497
Practice Address - Street 1:4141 NORTH S. HERRERA WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012
Practice Address - Country:US
Practice Address - Phone:602-512-2955
Practice Address - Fax:602-265-3497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X
AZNCI-447314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ344432Medicaid
AZ344432Medicaid