MEDICARE: SKYLARK ACH LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	3104A0625X	Assisted Living Facility (Mental Illness)
2	3104A0630X	Assisted Living Facility (Behavioral Disturbances)
3	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1952781247
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKYLARK ACH LLC

Provider Business Mailing Address
First Line	:	12034 N 46TH LN
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85304-3012
Country	:	US
Telephone Number	:	623-776-1477
Fax Number	:

Provider Business Practice Location Address
First Line	:	12034 N 46TH LN
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85304-3012
Country	:	US
Telephone Number	:	623-776-1477
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PAUL V PETRINI
Credential	:
Telephone Number	:	602-486-3001

Provider Enumeration Date	:	06/02/2015
Last Update Date	:	06/02/2015

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Directions to “SKYLARK ACH LLC ” Practice Location

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