Provider Demographics
NPI:1821355215
Name:TWILIGHT HAVEN III
Entity Type:Organization
Organization Name:TWILIGHT HAVEN III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAREGIVER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUSTYNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHATKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-819-4951
Mailing Address - Street 1:233 S. 123RD DR.
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-8043
Mailing Address - Country:US
Mailing Address - Phone:623-234-4034
Mailing Address - Fax:623-234-4525
Practice Address - Street 1:233 S. 123RD DR.
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-8043
Practice Address - Country:US
Practice Address - Phone:623-234-4034
Practice Address - Fax:623-234-4525
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TWILIGHT HAVEN - ASSISTED LIVING HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL85714372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty