Provider Demographics
NPI:1952820557
Name:POPS PROVISIONAL PLACE LLC
Entity Type:Organization
Organization Name:POPS PROVISIONAL PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:DIANNE
Authorized Official - Last Name:CRAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:623-693-3112
Mailing Address - Street 1:29741 W AMELIA AVE
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-7169
Mailing Address - Country:US
Mailing Address - Phone:623-693-3112
Mailing Address - Fax:623-434-3882
Practice Address - Street 1:29741 W AMELIA AVE
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85396-7169
Practice Address - Country:US
Practice Address - Phone:623-693-3112
Practice Address - Fax:623-434-3882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ044613164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty