MEDICARE: EL MIRAGE GROUP HOME 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	:	1174247332
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EL MIRAGE GROUP HOME LLC

Provider Business Mailing Address
First Line	:	13045 W PORT ROYALE LN
Second Line	:
City	:	EL MIRAGE
State	:	AZ
Zip	:	85335-3428
Country	:	US
Telephone Number	:	623-694-5101
Fax Number	:

Provider Business Practice Location Address
First Line	:	13045 W PORT ROYALE LN
Second Line	:
City	:	EL MIRAGE
State	:	AZ
Zip	:	85335-3428
Country	:	US
Telephone Number	:	623-694-5101
Fax Number	:

Authorized Official
Title or Position	:	MEMBER/MANAGER
Name	:	CORNELIA EDOH
Credential	:
Telephone Number	:	623-694-5101

Provider Enumeration Date	:	09/30/2022
Last Update Date	:	09/30/2022

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Directions to “EL MIRAGE GROUP HOME LLC ” Practice Location

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