Provider Demographics
NPI:1831195460
Name:INFINIA AT DOUGLAS
Entity type:Organization
Organization Name:INFINIA AT DOUGLAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-295-8000
Mailing Address - Street 1:1400 N SAN ANTONIO AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-2434
Mailing Address - Country:US
Mailing Address - Phone:520-364-7937
Mailing Address - Fax:520-805-9146
Practice Address - Street 1:1400 N SAN ANTONIO AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-2434
Practice Address - Country:US
Practice Address - Phone:520-364-7937
Practice Address - Fax:520-805-9146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCI-388314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ707416Medicaid
AZ707416Medicaid