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NPI Code Detail

MEDICARE: 19TH AVENUE OPERATIONS, LLC

MEDICARE: 19TH AVENUE OPERATIONS, 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
1310400000XAssisted Living FacilityAL10014CAZ
2310400000XAssisted Living FacilityAL10013CAZ
3314000000XSkilled Nursing FacilityNCI-2694AZ

General Provider Information

NPI Number : 1649627423
Entity Type Code : Organization
Provider Name (Legal Business Name) : 19TH AVENUE OPERATIONS, LLC
Provider Business Mailing Address
First Line : 1000 CORPORATE POINTE
Second Line : SUITE 100
City : CULVER CITY
State : CA
Zip : 90230-7690
Country : US
Telephone Number : 310-337-1929
Fax Number : 310-861-1661
Provider Business Practice Location Address
First Line : 6246 N 19TH AVE
Second Line :
City : PHOENIX
State : AZ
Zip : 85015-1511
Country : US
Telephone Number : 602-433-6300
Fax Number : 602-433-6458
Authorized Official
Title or Position : AUTHORIZED REPRESENTATIVE
Name : TRACY L. CLARK JR.
Credential :
Telephone Number : 310-337-1929
Provider Enumeration Date : 05/20/2016
Last Update Date : 01/04/2017

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Directions to “19TH AVENUE OPERATIONS, LLC ” Practice Location

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