Provider Demographics
NPI:1780029835
Name:SCOTTSDALE ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:SCOTTSDALE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-268-7726
Mailing Address - Street 1:6215 E SHEA BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-5425
Mailing Address - Country:US
Mailing Address - Phone:480-268-7726
Mailing Address - Fax:480-361-8732
Practice Address - Street 1:6215 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5425
Practice Address - Country:US
Practice Address - Phone:480-268-7726
Practice Address - Fax:480-361-8732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8778H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ717256Medicaid