Healthcare Provider Details

I. General information

NPI: 1295084440
Provider Name (Legal Business Name): WINDSOR PALM VALLEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13575 W MCDOWELL RD
GOODYEAR AZ
85395-2604
US

IV. Provider business mailing address

9200 W SUNSET BLVD
WEST HOLLYWOOD CA
90069-3502
US

V. Phone/Fax

Practice location:
  • Phone: 623-536-9911
  • Fax: 623-536-9502
Mailing address:
  • Phone: 310-385-1076
  • Fax: 310-595-3736

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: LEE SAMSON
Title or Position: MANAGING MEMBER, WINDSOR OMG HOLDIN
Credential:
Phone: 310-385-1090