Provider Demographics
NPI:1538652540
Name:AVISTA SENIOR LIVING DESERT SPRINGS, LLC
Entity Type:Organization
Organization Name:AVISTA SENIOR LIVING DESERT SPRINGS, LLC
Other - Org Name:AVISTA SENIOR LIVING NORTH MOUNTAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:FINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-244-9173
Mailing Address - Street 1:350 E EVA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2564
Mailing Address - Country:US
Mailing Address - Phone:602-997-6224
Mailing Address - Fax:602-944-4199
Practice Address - Street 1:350 E EVA ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2564
Practice Address - Country:US
Practice Address - Phone:602-997-6224
Practice Address - Fax:602-944-4199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8638C310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ677385Medicaid