Provider Demographics
NPI:1932105962
Name:LIFESTREAM COMPLETE SENIOR LIVING AT SUN RIDGE INC
Entity Type:Organization
Organization Name:LIFESTREAM COMPLETE SENIOR LIVING AT SUN RIDGE INC
Other - Org Name:LIFESTREAM AT SUN RIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-933-3333
Mailing Address - Street 1:12215 W BELL RD
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-9640
Mailing Address - Country:US
Mailing Address - Phone:623-583-5482
Mailing Address - Fax:623-583-1465
Practice Address - Street 1:12215 W BELL RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9640
Practice Address - Country:US
Practice Address - Phone:623-583-5482
Practice Address - Fax:623-583-1465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCI-406314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ390922Medicaid
AZ1025242OtherMERCY CARE ADVANTAGE
AZAZ0402330OtherBLUE CROSS BLUE SHIELD
AZ035243Medicare ID - Type UnspecifiedMEDICARE PROVIDER #