Provider Demographics
NPI:1114262292
Name:BOULDER GARDENS ASSISTANT LIVING, LLC
Entity Type:Organization
Organization Name:BOULDER GARDENS ASSISTANT LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-352-3019
Mailing Address - Street 1:150 N LA CANADA DR
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-3129
Mailing Address - Country:US
Mailing Address - Phone:520-352-3018
Mailing Address - Fax:520-393-1044
Practice Address - Street 1:860 DOUGHERTY ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1841
Practice Address - Country:US
Practice Address - Phone:928-778-9667
Practice Address - Fax:520-393-1044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL1494C310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAL1494COtherSTATE LICENSE