Provider Demographics
NPI:1497109292
Name:THE EAGLE WATCH BHS QUINTANA
Entity Type:Organization
Organization Name:THE EAGLE WATCH BHS QUINTANA
Other - Org Name:QUINTANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KAMAU
Authorized Official - Suffix:
Authorized Official - Credentials:ADMIN
Authorized Official - Phone:602-369-2609
Mailing Address - Street 1:4145 E MEGAN ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-7736
Mailing Address - Country:US
Mailing Address - Phone:602-369-2609
Mailing Address - Fax:480-207-1420
Practice Address - Street 1:4145 E MEGAN ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-7736
Practice Address - Country:US
Practice Address - Phone:602-369-2609
Practice Address - Fax:480-207-1420
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE EAGLE WATCH BHS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-18
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH47053104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances