Provider Demographics
NPI:1922451665
Name:ADVANCED SUPPORTED LIVING SERVICES, LLC
Entity Type:Organization
Organization Name:ADVANCED SUPPORTED LIVING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CHURCHILL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:480-548-7446
Mailing Address - Street 1:20403 N LAKE PLEASANT RD
Mailing Address - Street 2:SUITE 117-232
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9702
Mailing Address - Country:US
Mailing Address - Phone:480-548-7446
Mailing Address - Fax:480-907-1744
Practice Address - Street 1:20403 N LAKE PLEASANT RD
Practice Address - Street 2:SUITE 117-232
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-9702
Practice Address - Country:US
Practice Address - Phone:480-548-7446
Practice Address - Fax:480-907-1744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care