Provider Demographics
NPI:1558954552
Name:MIRABELLA AT ASU, INC
Entity Type:Organization
Organization Name:MIRABELLA AT ASU, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SHOLTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-646-3422
Mailing Address - Street 1:1 W MAIN ST STE 303
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-2796
Mailing Address - Country:US
Mailing Address - Phone:888-724-6424
Mailing Address - Fax:
Practice Address - Street 1:65 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-1091
Practice Address - Country:US
Practice Address - Phone:602-777-7701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility