Provider Demographics
NPI:1831322676
Name:HACIENDA SKILLED NURSING FACILITY
Entity Type:Organization
Organization Name:HACIENDA SKILLED NURSING FACILITY
Other - Org Name:HACIENDA SNF TRANSPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:SKURDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-243-4231
Mailing Address - Street 1:1402 E SOUTH MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-7925
Mailing Address - Country:US
Mailing Address - Phone:602-243-4231
Mailing Address - Fax:602-323-5988
Practice Address - Street 1:1402 E SOUTH MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-7925
Practice Address - Country:US
Practice Address - Phone:602-243-4231
Practice Address - Fax:602-323-5988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLTC 01953140N1450X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ544032Medicaid
AZLTC 0195OtherSTATE LICENSE
AZ03D1096517OtherCLIA
AZ03D1096517OtherCLIA