Provider Demographics
NPI:1528586195
Name:LIVE WELL ASSISTED LIVING
Entity Type:Organization
Organization Name:LIVE WELL ASSISTED LIVING
Other - Org Name:LIVE WELL RESIDENTIAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DESIRE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSINGIZWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-214-9544
Mailing Address - Street 1:10258 W WINDSOR BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85307-4124
Mailing Address - Country:US
Mailing Address - Phone:623-877-3293
Mailing Address - Fax:855-538-5652
Practice Address - Street 1:12634 W ESTERO LN
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-5156
Practice Address - Country:US
Practice Address - Phone:623-877-3293
Practice Address - Fax:855-538-5652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-5157320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860056Medicaid