Provider Demographics
NPI:1356885164
Name:ELITE ASSISTED LIVING HOME
Entity type:Organization
Organization Name:ELITE ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-743-9924
Mailing Address - Street 1:9559 W PINNACLE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-8715
Mailing Address - Country:US
Mailing Address - Phone:602-743-9924
Mailing Address - Fax:
Practice Address - Street 1:15928 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:WADDELL
Practice Address - State:AZ
Practice Address - Zip Code:85355-2001
Practice Address - Country:US
Practice Address - Phone:602-743-9924
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8356H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ498514Medicaid