Provider Demographics
NPI:1790812436
Name:LAKE HAVASU TOO, LLC
Entity Type:Organization
Organization Name:LAKE HAVASU TOO, LLC
Other - Org Name:PRESTIGE ASSISTED LIVING AT CLAREMONT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:VISLOCKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-735-7155
Mailing Address - Street 1:7700 NE PARKWAY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6648
Mailing Address - Country:US
Mailing Address - Phone:360-735-7155
Mailing Address - Fax:360-735-9416
Practice Address - Street 1:1221 CLAREMONT DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406-8684
Practice Address - Country:US
Practice Address - Phone:928-855-4843
Practice Address - Fax:928-855-2987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALC 4959310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ21159Medicaid