Provider Demographics
NPI:1396005195
Name:EMERITUS CORPORATION
Entity Type:Organization
Organization Name:EMERITUS CORPORATION
Other - Org Name:THE PERIDOT ASSISTED LIVING COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR MEDICAID SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-701-7249
Mailing Address - Street 1:3131 ELLIOTT AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-1044
Mailing Address - Country:US
Mailing Address - Phone:206-298-2909
Mailing Address - Fax:206-357-7292
Practice Address - Street 1:211 BRADSHAW DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4405
Practice Address - Country:US
Practice Address - Phone:928-777-5511
Practice Address - Fax:928-777-2155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8058C310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility