Provider Demographics
NPI:1144763731
Name:LIFESTREAM COMPLETE SENIOR LIVING AT NORTHEAST PHOENIX, INC.
Entity Type:Organization
Organization Name:LIFESTREAM COMPLETE SENIOR LIVING AT NORTHEAST PHOENIX, INC.
Other - Org Name:LIFESTREAM AT NORTHEAST PHOENIX GREEN HOUSE 84
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-933-3333
Mailing Address - Street 1:11555 W. PEORIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:YOUNGTOWN
Mailing Address - State:AZ
Mailing Address - Zip Code:85363
Mailing Address - Country:US
Mailing Address - Phone:623-933-3333
Mailing Address - Fax:623-972-7320
Practice Address - Street 1:20802 N. CAVE CREEK ROAD
Practice Address - Street 2:BUILDING 84
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024
Practice Address - Country:US
Practice Address - Phone:602-569-0508
Practice Address - Fax:602-569-0301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility