Provider Demographics
NPI:1689885543
Name:QUILTED CARE LTD. CO, DBA PEPPERTREE SQUARE
Entity Type:Organization
Organization Name:QUILTED CARE LTD. CO, DBA PEPPERTREE SQUARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-878-5115
Mailing Address - Street 1:10420 N 89TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-6453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10420 N 89TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-6453
Practice Address - Country:US
Practice Address - Phone:623-878-5115
Practice Address - Fax:623-878-1604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALC-4673261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service