Provider Demographics
NPI:1396872719
Name:HEARTHSTONE HOSPITAL - MESA, LLC
Entity type:Organization
Organization Name:HEARTHSTONE HOSPITAL - MESA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:DE SOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-945-7711
Mailing Address - Street 1:4440 N CIVIC CENTER PLZ
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-3513
Mailing Address - Country:US
Mailing Address - Phone:480-945-7711
Mailing Address - Fax:480-945-8266
Practice Address - Street 1:215 S POWER RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-5235
Practice Address - Country:US
Practice Address - Phone:480-945-7711
Practice Address - Fax:480-945-8266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSH 4388282E00000X
282N00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No282E00000XHospitalsLong Term Care Hospital
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ363701Medicaid
AZ035129OtherMEDICARE