Provider Demographics
NPI:1114172053
Name:SUPERSTITION MANOR ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:SUPERSTITION MANOR ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGUCKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-227-3458
Mailing Address - Street 1:201 W 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-7532
Mailing Address - Country:US
Mailing Address - Phone:480-288-9711
Mailing Address - Fax:480-288-8869
Practice Address - Street 1:201 W 20TH AVE
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85220-7532
Practice Address - Country:US
Practice Address - Phone:480-288-9711
Practice Address - Fax:480-228-8869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility