Provider Demographics
NPI:1326508953
Name:ILE, SAM
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:ILE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39506 N. DAISY MOUNTAIN DRIVE
Mailing Address - Street 2:STE 122-627
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086
Mailing Address - Country:US
Mailing Address - Phone:602-909-9550
Mailing Address - Fax:623-321-8797
Practice Address - Street 1:40401 N. COPPER BASIN TRAIL
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-8508
Practice Address - Country:US
Practice Address - Phone:602-909-9550
Practice Address - Fax:623-321-8797
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances