Provider Demographics
NPI:1881674414
Name:LIFESTREAM COMPLETE SENIOR LIVING AT THUNDERBIRD INC
Entity Type:Organization
Organization Name:LIFESTREAM COMPLETE SENIOR LIVING AT THUNDERBIRD INC
Other - Org Name:LIFESTREAM AT THUNDERBIRD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROD
Authorized Official - Middle Name:
Authorized Official - Last Name:KEMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-933-3333
Mailing Address - Street 1:13617 N 55TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-4701
Mailing Address - Country:US
Mailing Address - Phone:602-938-5500
Mailing Address - Fax:602-843-9530
Practice Address - Street 1:13617 N 55TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-4701
Practice Address - Country:US
Practice Address - Phone:602-938-5500
Practice Address - Fax:602-843-9530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALC-4809310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZEVC00600003119Medicaid
AZ622854Medicaid
AZE2103020Medicaid