MEDICARE: EMERITOL LO FLAGSTAFF LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1023674090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERITOL LO FLAGSTAFF LLC

Provider Business Mailing Address
First Line	:	2100 S WOODLANDS VILLAGE BLVD
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-2803
Country	:	US
Telephone Number	:	928-779-7045
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 S WOODLANDS VILLAGE BLVD
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-2803
Country	:	US
Telephone Number	:	928-779-7045
Fax Number	:

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	JOANNE K LESKOWICZ
Credential	:
Telephone Number	:	414-918-5000

Provider Enumeration Date	:	05/15/2019
Last Update Date	:	05/15/2019

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Directions to “EMERITOL LO FLAGSTAFF LLC ” Practice Location

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