Provider Demographics
NPI:1669197604
Name:MICLOS CAJIC, CAROLINA CRISTINA
Entity type:Individual
Prefix:
First Name:CAROLINA
Middle Name:CRISTINA
Last Name:MICLOS CAJIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 W KRISTAL WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-6141
Mailing Address - Country:US
Mailing Address - Phone:602-410-3125
Mailing Address - Fax:928-433-8225
Practice Address - Street 1:3407 W KRISTAL WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-6141
Practice Address - Country:US
Practice Address - Phone:602-410-3125
Practice Address - Fax:928-433-8225
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL12339H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility