Provider Demographics
NPI:1093467623
Name:BLACKBIRD SENIOR LIVING, INC.
Entity Type:Organization
Organization Name:BLACKBIRD SENIOR LIVING, INC.
Other - Org Name:THE CITADEL ASSISTED LIVING FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:520 S HIGLEY RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2153
Mailing Address - Country:US
Mailing Address - Phone:480-832-7600
Mailing Address - Fax:480-832-3860
Practice Address - Street 1:520 S HIGLEY RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2153
Practice Address - Country:US
Practice Address - Phone:480-832-7600
Practice Address - Fax:480-832-3860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-25
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility