Provider Demographics
NPI:1609925718
Name:MADERA ASSISTED LIVING HOME
Entity Type:Organization
Organization Name:MADERA ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HEYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-663-3652
Mailing Address - Street 1:707 W PALO VERDE ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-5841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 W PALO VERDE ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-5841
Practice Address - Country:US
Practice Address - Phone:480-663-3652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-5008310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ002639252OtherEVERCARE PARADIGM ID NO.