Healthcare Provider Details

I. General information

NPI: 1407482920
Provider Name (Legal Business Name): FLAGSTAFF TRANSITIONAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 N PINE CLIFF DR
FLAGSTAFF AZ
86001-3269
US

IV. Provider business mailing address

1107 HAZELTINE BOULEVARD, BOX 26
CHASKA MN
55318
US

V. Phone/Fax

Practice location:
  • Phone: 928-440-2350
  • Fax:
Mailing address:
  • Phone: 952-361-8900
  • Fax: 952-361-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: RANDALL W. BENSON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 952-361-8000