Provider Demographics
NPI:1083698328
Name:THE LODGE AT 14TH ST.
Entity Type:Organization
Organization Name:THE LODGE AT 14TH ST.
Other - Org Name:CRYSTAL LODGE INVESTORS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-279-1033
Mailing Address - Street 1:2941 N. 14TH ST.
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5604
Mailing Address - Country:US
Mailing Address - Phone:602-279-1033
Mailing Address - Fax:602-277-5367
Practice Address - Street 1:2941 N 14TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5604
Practice Address - Country:US
Practice Address - Phone:602-279-1033
Practice Address - Fax:602-277-5604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALC 4746261Q00000X
AZALC-4746282J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282J00000XHospitalsReligious Nonmedical Health Care Institution
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ629256Medicaid
AZ629-256Medicaid