Provider Demographics
NPI:1912536368
Name:AGUA FRIA SENIOR LIVING, LLC
Entity Type:Organization
Organization Name:AGUA FRIA SENIOR LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-368-5755
Mailing Address - Street 1:14650 N 78TH WAY STE B
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-2970
Mailing Address - Country:US
Mailing Address - Phone:602-544-3195
Mailing Address - Fax:602-553-7574
Practice Address - Street 1:8880 N 107TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-2908
Practice Address - Country:US
Practice Address - Phone:623-266-0999
Practice Address - Fax:623-215-7703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ527346Medicaid
AZAL10709COtherARIZONA DEPARTMENT OF HEALTH SERVICES