Provider Demographics
NPI:1235496902
Name:PEPPERTREE QUILT, LLC
Entity Type:Organization
Organization Name:PEPPERTREE QUILT, LLC
Other - Org Name:PEPPERTREE SQUARE ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:WITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-797-8735
Mailing Address - Street 1:5353 WYOMING BLVD NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3132
Mailing Address - Country:US
Mailing Address - Phone:505-797-8735
Mailing Address - Fax:505-797-9003
Practice Address - Street 1:10420 N 89TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-6453
Practice Address - Country:US
Practice Address - Phone:623-878-5115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL4725C310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility