Provider Demographics
NPI:1073859641
Name:SIERRA VISTA ASSISTANT LIVING LLC
Entity Type:Organization
Organization Name:SIERRA VISTA ASSISTANT LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIDEL
Authorized Official - Suffix:
Authorized Official - Credentials:MASTER DEGREE
Authorized Official - Phone:602-628-3642
Mailing Address - Street 1:3331 W IAN DR
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-3805
Mailing Address - Country:US
Mailing Address - Phone:602-628-3642
Mailing Address - Fax:
Practice Address - Street 1:3331 W IAN DR
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-3805
Practice Address - Country:US
Practice Address - Phone:602-628-3642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-29
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8772H320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ10733859641Medicaid