Provider Demographics
NPI:1689051062
Name:RUSTIC RIVER HOMES
Entity Type:Organization
Organization Name:RUSTIC RIVER HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PLEITNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-244-8457
Mailing Address - Street 1:2124 E FIRESTONE DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-4634
Mailing Address - Country:US
Mailing Address - Phone:480-244-8457
Mailing Address - Fax:480-659-1076
Practice Address - Street 1:2124 E FIRESTONE DR
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-4634
Practice Address - Country:US
Practice Address - Phone:480-244-8457
Practice Address - Fax:480-659-1076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL9097H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ835207Medicaid