Provider Demographics
NPI:1518263052
Name:SUN VALLEY LODGE
Entity Type:Organization
Organization Name:SUN VALLEY LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FAHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-933-0137
Mailing Address - Street 1:12415 N 103RD AVE
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3509
Mailing Address - Country:US
Mailing Address - Phone:623-933-0137
Mailing Address - Fax:
Practice Address - Street 1:12415 N 103RD AVE
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3509
Practice Address - Country:US
Practice Address - Phone:623-933-0137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-01
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCI-258314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility