Provider Demographics
NPI:1356864037
Name:LEISURE TIMES HOME LLC
Entity Type:Organization
Organization Name:LEISURE TIMES HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CIMPEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-399-2349
Mailing Address - Street 1:15653 W REDFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-5628
Mailing Address - Country:US
Mailing Address - Phone:623-399-2349
Mailing Address - Fax:
Practice Address - Street 1:11678 W YUCCA CT
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-2518
Practice Address - Country:US
Practice Address - Phone:623-399-2349
Practice Address - Fax:623-505-4239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-25
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10340H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility