Provider Demographics
NPI:1346806072
Name:PARK PLACE RESIDENCES LLC
Entity Type:Organization
Organization Name:PARK PLACE RESIDENCES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CASSI
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-868-8697
Mailing Address - Street 1:67 S HIGLEY RD STE 103-208
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1166
Mailing Address - Country:US
Mailing Address - Phone:480-868-8697
Mailing Address - Fax:
Practice Address - Street 1:7150 E GARY RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5217
Practice Address - Country:US
Practice Address - Phone:480-868-8697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-17
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances