Provider Demographics
NPI:1770849648
Name:DES MOINES SPECIALIZED CARE
Entity Type:Organization
Organization Name:DES MOINES SPECIALIZED CARE
Other - Org Name:SPECIALIZED ASSISTED LIVING, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUCIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-793-6265
Mailing Address - Street 1:15029 N. THOMPSON PEAK PKWAY
Mailing Address - Street 2:SUITE B-111, #418
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260
Mailing Address - Country:US
Mailing Address - Phone:602-793-6265
Mailing Address - Fax:480-621-5842
Practice Address - Street 1:15029 N THOMPSON PEAK PKWY
Practice Address - Street 2:SUITE B-111, #418
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-2217
Practice Address - Country:US
Practice Address - Phone:602-793-6265
Practice Address - Fax:480-621-5842
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALIZED ASSISTED LIVING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ136599310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ136599Medicaid