Provider Demographics
NPI:1497013940
Name:PAYSON'S OPEN DOOR
Entity Type:Organization
Organization Name:PAYSON'S OPEN DOOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:928-474-2096
Mailing Address - Street 1:1008 S BUTTE CREST CIR
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-5603
Mailing Address - Country:US
Mailing Address - Phone:928-474-2096
Mailing Address - Fax:
Practice Address - Street 1:1008 S BUTTE CREST CIR
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5603
Practice Address - Country:US
Practice Address - Phone:928-474-2096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8465H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility