Provider Demographics
NPI:1801548474
Name:HOLLYHOCK ASSISTED LIVING LLC
Entity type:Organization
Organization Name:HOLLYHOCK ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-332-0780
Mailing Address - Street 1:16552 N HOLLYHOCK ST
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-3667
Mailing Address - Country:US
Mailing Address - Phone:160-233-2078
Mailing Address - Fax:
Practice Address - Street 1:16552 N HOLLYHOCK ST
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-3667
Practice Address - Country:US
Practice Address - Phone:160-233-2078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ05Medicaid