Provider Demographics
NPI:1851390330
Name:COPPER MOUNTAIN INN, INC.
Entity Type:Organization
Organization Name:COPPER MOUNTAIN INN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:928-425-5721
Mailing Address - Street 1:1100 E MONROE ST
Mailing Address - Street 2:
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501-1363
Mailing Address - Country:US
Mailing Address - Phone:928-425-5721
Mailing Address - Fax:928-425-3745
Practice Address - Street 1:1100 E MONROE ST
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-1363
Practice Address - Country:US
Practice Address - Phone:928-425-5721
Practice Address - Fax:928-425-3745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCI 412314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ558471Medicaid
AZ558471Medicaid