Provider Demographics
NPI:1942355219
Name:LB PHOENIX BETHANY HOME ROAD LLC
Entity Type:Organization
Organization Name:LB PHOENIX BETHANY HOME ROAD LLC
Other - Org Name:CHRIS RIDGE VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BAUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-433-6416
Mailing Address - Street 1:6246 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1511
Mailing Address - Country:US
Mailing Address - Phone:602-433-6416
Mailing Address - Fax:602-433-6458
Practice Address - Street 1:6246 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1511
Practice Address - Country:US
Practice Address - Phone:602-433-6416
Practice Address - Fax:602-433-6458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ035116314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ035116Medicare ID - Type Unspecified