Provider Demographics
NPI:1780858522
Name:PHOENIX MOUNTAIN NURSING CENTER, INC.
Entity Type:Organization
Organization Name:PHOENIX MOUNTAIN NURSING CENTER, INC.
Other - Org Name:PHOENIX MOUNTAIN NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARY
Authorized Official - Middle Name:B
Authorized Official - Last Name:HARKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-734-0533
Mailing Address - Street 1:13232 N TATUM BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-6459
Mailing Address - Country:US
Mailing Address - Phone:602-996-5200
Mailing Address - Fax:602-996-6160
Practice Address - Street 1:13232 N TATUM BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-6459
Practice Address - Country:US
Practice Address - Phone:602-996-5200
Practice Address - Fax:602-996-6160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCI-2673314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ035072Medicare Oscar/Certification