Provider Demographics
NPI:1083060594
Name:DPAC HOLDINGS LLC
Entity Type:Organization
Organization Name:DPAC HOLDINGS LLC
Other - Org Name:DESERT PALM ADULT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZVAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-331-8495
Mailing Address - Street 1:1214 E PALMAIRE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-5429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1214 E PALMAIRE DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5429
Practice Address - Country:US
Practice Address - Phone:602-943-4842
Practice Address - Fax:877-867-5390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-13
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL9483H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ476089Medicaid