Provider Demographics
NPI:1932722402
Name:DESERT WILDFLOWER ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:DESERT WILDFLOWER ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:MARIE WINN
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-740-6693
Mailing Address - Street 1:5252 SW IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-1617
Mailing Address - Country:US
Mailing Address - Phone:503-740-6693
Mailing Address - Fax:
Practice Address - Street 1:8207 W NICOLET AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-1822
Practice Address - Country:US
Practice Address - Phone:623-252-9506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility