Provider Demographics
NPI:1336561521
Name:COPPER HEALTH ORO VALLEY LLC
Entity Type:Organization
Organization Name:COPPER HEALTH ORO VALLEY LLC
Other - Org Name:COPPER HEALTH ORO VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:TERRENCE
Authorized Official - Last Name:MCNELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-991-9062
Mailing Address - Street 1:3602 E GREENWAY RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4648
Mailing Address - Country:US
Mailing Address - Phone:602-368-8203
Mailing Address - Fax:602-368-8211
Practice Address - Street 1:1119 E RANCHO VISTOSO BLVD
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-9106
Practice Address - Country:US
Practice Address - Phone:520-823-4669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-08
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCI2725314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZNCI2725OtherARIZONA DEPT. OF HEALTH SERVICES
AZ035288Medicare Oscar/Certification