Provider Demographics
NPI:1720376742
Name:DESERT EMERALD ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:DESERT EMERALD ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOMONGCAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-580-7035
Mailing Address - Street 1:4526 N 82ND ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-1702
Mailing Address - Country:US
Mailing Address - Phone:480-203-2263
Mailing Address - Fax:480-773-7279
Practice Address - Street 1:4526 N 82ND ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-1702
Practice Address - Country:US
Practice Address - Phone:480-203-2263
Practice Address - Fax:480-773-7279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL6530H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility