Provider Demographics
NPI:1659936433
Name:EAGLE PASS SENIOR LIVING LLC
Entity Type:Organization
Organization Name:EAGLE PASS SENIOR LIVING LLC
Other - Org Name:AMARSI ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-401-1369
Mailing Address - Street 1:5125 N 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-7453
Mailing Address - Country:US
Mailing Address - Phone:623-915-5720
Mailing Address - Fax:
Practice Address - Street 1:5125 N 58TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-7453
Practice Address - Country:US
Practice Address - Phone:623-915-5720
Practice Address - Fax:623-931-8776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-07
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility