Provider Demographics
NPI:1861442063
Name:FREEDOM PLAZA LP
Entity Type:Organization
Organization Name:FREEDOM PLAZA LP
Other - Org Name:FREEDOM PLAZA CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-2250
Mailing Address - Street 1:13373 N PLAZA DEL RIO BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4873
Mailing Address - Country:US
Mailing Address - Phone:623-972-1776
Mailing Address - Fax:
Practice Address - Street 1:13373 N PLAZA DEL RIO BLVD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4873
Practice Address - Country:US
Practice Address - Phone:623-972-1776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCI-2630314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ035256Medicare ID - Type UnspecifiedMEDICARE PROVIDER #