Provider Demographics
NPI:1760477541
Name:24TH STREET HEALTHCARE ASSOCIATES LLC
Entity Type:Organization
Organization Name:24TH STREET HEALTHCARE ASSOCIATES LLC
Other - Org Name:DESERT TERRACE HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:2509 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-1805
Mailing Address - Country:US
Mailing Address - Phone:602-273-1347
Mailing Address - Fax:602-273-6260
Practice Address - Street 1:2509 N 24TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-1805
Practice Address - Country:US
Practice Address - Phone:602-273-1347
Practice Address - Fax:602-273-6260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ688062Medicaid
CA035014Medicare Oscar/Certification