Provider Demographics
NPI:1285837872
Name:PROVIDENCE MANOIR ASSISTED LIVING
Entity Type:Organization
Organization Name:PROVIDENCE MANOIR ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMISSIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JEAN-MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-388-1140
Mailing Address - Street 1:6567 S GARNET WAY
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-7255
Mailing Address - Country:US
Mailing Address - Phone:480-388-1140
Mailing Address - Fax:480-219-1889
Practice Address - Street 1:6567 S GARNET WAY
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-7255
Practice Address - Country:US
Practice Address - Phone:480-388-1140
Practice Address - Fax:480-219-1889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-09
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-5829310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ162761OtherALTCS PROVIDER