Provider Demographics
NPI:1780413278
Name:BOT, LORENA
Entity type:Individual
Prefix:
First Name:LORENA
Middle Name:
Last Name:BOT
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 1:1929 W SPUR DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-1721
Mailing Address - Country:US
Mailing Address - Phone:503-964-8556
Mailing Address - Fax:
Practice Address - Street 1:1929 W SPUR DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-1721
Practice Address - Country:US
Practice Address - Phone:503-964-8556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL12049H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility