Provider Demographics
NPI:1003189754
Name:CASA DE ANGELES ASSISTED LIVING INC.
Entity type:Organization
Organization Name:CASA DE ANGELES ASSISTED LIVING INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ILIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-873-8419
Mailing Address - Street 1:P.O. BOX 726
Mailing Address - Street 2:
Mailing Address - City:PEARCE
Mailing Address - State:AZ
Mailing Address - Zip Code:85625
Mailing Address - Country:US
Mailing Address - Phone:520-826-4065
Mailing Address - Fax:520-826-4065
Practice Address - Street 1:457 N. IRONWOOD CT.
Practice Address - Street 2:
Practice Address - City:PEARCE
Practice Address - State:AZ
Practice Address - Zip Code:85625
Practice Address - Country:US
Practice Address - Phone:520-826-4065
Practice Address - Fax:520-826-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8631H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ682106Medicaid