Provider Demographics
NPI:1033571419
Name:AN ENCHANTED ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:AN ENCHANTED ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEFAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-550-6653
Mailing Address - Street 1:15924 W MAUNA LOA LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-5141
Mailing Address - Country:US
Mailing Address - Phone:602-550-6653
Mailing Address - Fax:
Practice Address - Street 1:15924 W MAUNA LOA LN
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379
Practice Address - Country:US
Practice Address - Phone:602-550-6653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL6985H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility