Provider Demographics
NPI:1912142324
Name:PONDEROSA ASSISTED LIVING
Entity Type:Organization
Organization Name:PONDEROSA ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:E
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-635-4179
Mailing Address - Street 1:PO BOX 16153
Mailing Address - Street 2:
Mailing Address - City:BELLEMONT
Mailing Address - State:AZ
Mailing Address - Zip Code:86015-6153
Mailing Address - Country:US
Mailing Address - Phone:928-635-4199
Mailing Address - Fax:
Practice Address - Street 1:826 HEREFORD DR
Practice Address - Street 2:
Practice Address - City:WILLIAMS
Practice Address - State:AZ
Practice Address - Zip Code:86046-9789
Practice Address - Country:US
Practice Address - Phone:928-635-4179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-15
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility