Provider Demographics
NPI:1841782638
Name:GOLDWATER LEGACY ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:GOLDWATER LEGACY ASSISTED LIVING LLC
Other - Org Name:GOLD WATER ASSISTED LIVING II
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TOHATAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-544-9334
Mailing Address - Street 1:6640 W PINNACLE PEAK RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-3409
Mailing Address - Country:US
Mailing Address - Phone:480-544-9334
Mailing Address - Fax:
Practice Address - Street 1:6640 W PINNACLE PEAK RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-3409
Practice Address - Country:US
Practice Address - Phone:480-544-9334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL9797H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherPRIVATE PAY