Provider Demographics
NPI:1356986699
Name:FRIENDSHIP GARDENS ASSISTED LIVING HOME
Entity type:Organization
Organization Name:FRIENDSHIP GARDENS ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:352-228-1220
Mailing Address - Street 1:1909 MORRIS ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-3125
Mailing Address - Country:US
Mailing Address - Phone:352-228-1220
Mailing Address - Fax:505-503-6978
Practice Address - Street 1:1909 MORRIS ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-3125
Practice Address - Country:US
Practice Address - Phone:352-228-1220
Practice Address - Fax:505-503-6978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1700223823OtherINDIAN HEALTH SERVICE