Provider Demographics
NPI:1235331216
Name:DESERT LAKE ASSISTED LIVING HOME
Entity Type:Organization
Organization Name:DESERT LAKE ASSISTED LIVING HOME
Other - Org Name:STEVEN A. LAZORCHAK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:LAZORCHAK
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:480-855-1975
Mailing Address - Street 1:4227 W CROCUS DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-5316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1040 N VILLAS LN
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-9006
Practice Address - Country:US
Practice Address - Phone:480-821-0203
Practice Address - Fax:480-821-0203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-02
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH5646310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZALH5646OtherFACILITY LICENSE
AZA195847OtherALTCS PROVER NUMBER