Provider Demographics
NPI:1992032031
Name:FAMILY CARE ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:FAMILY CARE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAVEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MICULIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-533-5131
Mailing Address - Street 1:4327 W WAHALLA LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7344
Mailing Address - Country:US
Mailing Address - Phone:623-533-5131
Mailing Address - Fax:623-565-8040
Practice Address - Street 1:4327 W WAHALLA LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7344
Practice Address - Country:US
Practice Address - Phone:623-533-5131
Practice Address - Fax:623-565-8040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL7379H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ418233OtherAHCCCS