Provider Demographics
NPI:1720560410
Name:ALPHA ASSISTED LIVING
Entity Type:Organization
Organization Name:ALPHA ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONSTANTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-705-4430
Mailing Address - Street 1:18802 N 38TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-2617
Mailing Address - Country:US
Mailing Address - Phone:602-705-4430
Mailing Address - Fax:
Practice Address - Street 1:18802 N 38TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-2617
Practice Address - Country:US
Practice Address - Phone:602-705-4430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-30
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8742H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility