Healthcare Provider Details

I. General information

NPI: 1114172053
Provider Name (Legal Business Name): SUPERSTITION MANOR ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W 20TH AVE
APACHE JUNCTION AZ
85220-7532
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 480-288-9711
  • Fax: 480-228-8869
Mailing address:
  • Phone: 480-288-9711
  • Fax: 480-288-8869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. BRUCE BOGUCKI
Title or Position: OWNER MANAGER
Credential:
Phone: 480-227-3458