Provider Demographics
NPI:1619047305
Name:ST. MICHAEL'S MANOR
Entity Type:Organization
Organization Name:ST. MICHAEL'S MANOR
Other - Org Name:TERESITA AND MARIO CABACUNGAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESITA
Authorized Official - Middle Name:ARCENA
Authorized Official - Last Name:CABACUNGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-673-3214
Mailing Address - Street 1:8449 W SHAW BUTTE DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-8160
Mailing Address - Country:US
Mailing Address - Phone:623-486-5987
Mailing Address - Fax:623-328-5530
Practice Address - Street 1:8449 W SHAW BUTTE DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-8160
Practice Address - Country:US
Practice Address - Phone:623-486-5987
Practice Address - Fax:623-328-5530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2008-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-4384311ZA0620X
AZALH-5308311ZA0620X
AZALH6365311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ827777OtherAHCCCS
AZ966244OtherAHCCCS