Provider Demographics
NPI: | 1376059550 |
---|---|
Name: | IVY LANE ASSISTED LIVING,LLC |
Entity Type: | Organization |
Organization Name: | IVY LANE ASSISTED LIVING,LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DENISA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | KAPORALIS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 602-339-3617 |
Mailing Address - Street 1: | 18379 W IVY LN |
Mailing Address - Street 2: | |
Mailing Address - City: | SURPRISE |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85388-2367 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 623-544-2805 |
Mailing Address - Fax: | 623-399-6561 |
Practice Address - Street 1: | 18379 W IVY LN |
Practice Address - Street 2: | |
Practice Address - City: | SURPRISE |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85388-2367 |
Practice Address - Country: | US |
Practice Address - Phone: | 623-544-2805 |
Practice Address - Fax: | 623-399-6561 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-12-24 |
Last Update Date: | 2017-12-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | AL10549H | 311ZA0620X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 311ZA0620X | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |