Provider Demographics
NPI:1912511999
Name:FANAKA ENTERPRISES LLC
Entity Type:Organization
Organization Name:FANAKA ENTERPRISES LLC
Other - Org Name:LA PAZ ASSISTED LIVING III
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CATE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIBERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-301-9021
Mailing Address - Street 1:3925 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-1001
Mailing Address - Country:US
Mailing Address - Phone:520-771-9971
Mailing Address - Fax:520-771-9971
Practice Address - Street 1:3925 E 1ST ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1001
Practice Address - Country:US
Practice Address - Phone:520-771-9971
Practice Address - Fax:520-771-9971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ008631Medicaid