Provider Demographics
NPI:1952457392
Name:JANELLE HULTMAN
Entity Type:Organization
Organization Name:JANELLE HULTMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANELLE
Authorized Official - Middle Name:EVONNE
Authorized Official - Last Name:HULTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-581-5687
Mailing Address - Street 1:13401 W FARGO DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-5205
Mailing Address - Country:US
Mailing Address - Phone:623-581-5687
Mailing Address - Fax:
Practice Address - Street 1:13401 W FARGO DR
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-5205
Practice Address - Country:US
Practice Address - Phone:623-581-5687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-26953104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ118632Medicaid
AZBH-2695OtherSTATE LICENSE