Healthcare Provider Details

I. General information

NPI: 1609201128
Provider Name (Legal Business Name): SUPERSTITION MANOR ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2013
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W 20TH AVE
APACHE JUNCTION AZ
85120-7532
US

IV. Provider business mailing address

201 W 20TH AVE
APACHE JUNCTION AZ
85120-7532
US

V. Phone/Fax

Practice location:
  • Phone: 480-227-3458
  • Fax:
Mailing address:
  • Phone: 480-227-3458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: BRUCE BOGUCKI
Title or Position: OWNER/MEMBER
Credential:
Phone: 480-227-3458