Provider Demographics
NPI:1457409799
Name:PADILLAS RESIDENTIAL CARE
Entity Type:Organization
Organization Name:PADILLAS RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:IONA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-289-5430
Mailing Address - Street 1:1517 W THIRD ST
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-2919
Mailing Address - Country:US
Mailing Address - Phone:928-289-5430
Mailing Address - Fax:
Practice Address - Street 1:1517 W THIRD ST
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2919
Practice Address - Country:US
Practice Address - Phone:928-289-5430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-3002310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ767337Medicaid