Provider Demographics
NPI:1629198858
Name:ACTIVE ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:ACTIVE ASSISTED LIVING, LLC
Other - Org Name:COMFORT HAVEN OF MESA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:THARALSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-461-8272
Mailing Address - Street 1:1235 S GILBERT RD
Mailing Address - Street 2:STE 3, PMB 83
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6005
Mailing Address - Country:US
Mailing Address - Phone:480-461-8272
Mailing Address - Fax:480-461-4682
Practice Address - Street 1:758 S TOLTEC
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-3642
Practice Address - Country:US
Practice Address - Phone:480-461-8272
Practice Address - Fax:480-461-4682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-4567320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZALH-4567OtherASSISTED LIVING LICENSE