Provider Demographics
NPI:1811527047
Name:LIVE WELL ASSISTED LIVING
Entity type:Organization
Organization Name:LIVE WELL ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DESIRE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSINGIZWA
Authorized Official - Suffix:
Authorized Official - Credentials:BHT
Authorized Official - Phone:623-877-3764
Mailing Address - Street 1:6462 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-7604
Mailing Address - Country:US
Mailing Address - Phone:623-399-7824
Mailing Address - Fax:
Practice Address - Street 1:6462 S 4TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-7604
Practice Address - Country:US
Practice Address - Phone:623-399-7824
Practice Address - Fax:855-538-5652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities