Provider Demographics
NPI:1649627423
Name:19TH AVENUE OPERATIONS, LLC
Entity type:Organization
Organization Name:19TH AVENUE OPERATIONS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:310-337-1929
Mailing Address - Street 1:1000 CORPORATE POINTE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-7690
Mailing Address - Country:US
Mailing Address - Phone:310-337-1929
Mailing Address - Fax:310-861-1661
Practice Address - Street 1:6246 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1511
Practice Address - Country:US
Practice Address - Phone:602-433-6300
Practice Address - Fax:602-433-6458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10014C310400000X
AZAL10013C310400000X
AZNCI-2694314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ035116Medicare Oscar/Certification