Provider Demographics
NPI:1962855296
Name:ACSAYAN, ANGELO
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:
Last Name:ACSAYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 E MALLORY ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-1667
Mailing Address - Country:US
Mailing Address - Phone:480-654-8196
Mailing Address - Fax:480-275-2609
Practice Address - Street 1:2955 E MALLORY ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-1667
Practice Address - Country:US
Practice Address - Phone:480-654-8196
Practice Address - Fax:480-275-2609
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10036310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility