Provider Demographics
NPI:1477635415
Name:SOUTHWESTERN MEDICAL CENTERS AZ
Entity Type:Organization
Organization Name:SOUTHWESTERN MEDICAL CENTERS AZ
Other - Org Name:MEADOW PARK CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STUDER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:210-828-5686
Mailing Address - Street 1:864 DOUGHERTY ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1841
Mailing Address - Country:US
Mailing Address - Phone:928-778-9666
Mailing Address - Fax:
Practice Address - Street 1:864 DOUGHERTY ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1841
Practice Address - Country:US
Practice Address - Phone:928-778-9667
Practice Address - Fax:928-771-9620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4602314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ041088Medicaid
AZ041088Medicaid