Provider Demographics
NPI:1225800535
Name:ESTANCIA ASSISTED LIVING AT DANA PARK, LLC
Entity Type:Organization
Organization Name:ESTANCIA ASSISTED LIVING AT DANA PARK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ASHTON
Authorized Official - Middle Name:
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-243-3647
Mailing Address - Street 1:16543 E ELGIN ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-2003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4221 E HOLMES CIR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3321
Practice Address - Country:US
Practice Address - Phone:480-561-5590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility