Provider Demographics
NPI:1720602832
Name:CASA DE VIDA LIVING LLC
Entity Type:Organization
Organization Name:CASA DE VIDA LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BLUNT
Authorized Official - Suffix:
Authorized Official - Credentials:AL-MANAGER
Authorized Official - Phone:602-696-6249
Mailing Address - Street 1:7036 W PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-6921
Mailing Address - Country:US
Mailing Address - Phone:602-696-6249
Mailing Address - Fax:
Practice Address - Street 1:7036 W PARKWAY DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043-6921
Practice Address - Country:US
Practice Address - Phone:602-696-6249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility