Provider Demographics
NPI:1164670691
Name:VENTANA LAKES
Entity Type:Organization
Organization Name:VENTANA LAKES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:POP
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT MANAGER
Authorized Official - Phone:623-376-8411
Mailing Address - Street 1:20067N 110TH LANE
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85373-3331
Mailing Address - Country:US
Mailing Address - Phone:623-376-8411
Mailing Address - Fax:623-376-8411
Practice Address - Street 1:20067N 110TH LANE
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85373-3331
Practice Address - Country:US
Practice Address - Phone:623-376-8411
Practice Address - Fax:623-376-8411
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VENTANA LAKES - ASSISTED LIVING HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH2495310400000X
AZID539231310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAHCCCSID539231Medicaid
AZALH2495OtherLICENSE