Provider Demographics
NPI:1164606620
Name:VINEYARD ADULT CARE HOME
Entity Type:Organization
Organization Name:VINEYARD ADULT CARE HOME
Other - Org Name:SUNRISE ADULT CARE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CORNELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUPAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-847-1216
Mailing Address - Street 1:4415 W CAROL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-3814
Mailing Address - Country:US
Mailing Address - Phone:623-847-1216
Mailing Address - Fax:623-847-1216
Practice Address - Street 1:4415 W CAROL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-3814
Practice Address - Country:US
Practice Address - Phone:623-847-1216
Practice Address - Fax:623-847-1216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-6842311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home