Provider Demographics
NPI:1982464095
Name:1217 KENWOOD LLC
Entity Type:Organization
Organization Name:1217 KENWOOD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:LEAVITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-386-8092
Mailing Address - Street 1:3132 E EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-4708
Mailing Address - Country:US
Mailing Address - Phone:858-414-3340
Mailing Address - Fax:
Practice Address - Street 1:1217 E KENWOOD ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-1950
Practice Address - Country:US
Practice Address - Phone:858-386-8092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility