Provider Demographics
NPI:1336477520
Name:THE HARBOR LIGHHOUSE II
Entity Type:Organization
Organization Name:THE HARBOR LIGHHOUSE II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COSTEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TIRDEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-358-8604
Mailing Address - Street 1:4142 W GROVERS AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-2926
Mailing Address - Country:US
Mailing Address - Phone:602-358-8604
Mailing Address - Fax:602-606-2356
Practice Address - Street 1:4142 W GROVERS AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-2926
Practice Address - Country:US
Practice Address - Phone:602-358-8604
Practice Address - Fax:602-606-2356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-26
Last Update Date:2009-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-6343311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAHL-6343OtherASSISTED LIVING HOME LICENSE