Provider Demographics
NPI:1205824653
Name:ARIZONA EASTERN STAR RETIREMENT CENTER
Entity Type:Organization
Organization Name:ARIZONA EASTERN STAR RETIREMENT CENTER
Other - Org Name:ARIZONA EASTERN STAR HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PARHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-954-9178
Mailing Address - Street 1:4602 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:602-553-8344
Practice Address - Street 1:4602 N 24TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5253
Practice Address - Country:US
Practice Address - Phone:602-833-8344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALC-4559310400000X
AZNCI-307314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03-5209Medicare Oscar/Certification