Provider Demographics
NPI:1801099692
Name:EL MIRAGE GROUP HOME
Entity type:Organization
Organization Name:EL MIRAGE GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELA
Authorized Official - Middle Name:O
Authorized Official - Last Name:MICULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-367-6491
Mailing Address - Street 1:13045 W PORT ROYALE LN
Mailing Address - Street 2:
Mailing Address - City:EL MIRAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85335-3428
Mailing Address - Country:US
Mailing Address - Phone:602-367-6491
Mailing Address - Fax:623-582-8178
Practice Address - Street 1:13045 W PORT ROYALE LN
Practice Address - Street 2:
Practice Address - City:EL MIRAGE
Practice Address - State:AZ
Practice Address - Zip Code:85335-3428
Practice Address - Country:US
Practice Address - Phone:602-367-6491
Practice Address - Fax:623-582-8178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-5221310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility