Healthcare Provider Details

I. General information

NPI: 1922451665
Provider Name (Legal Business Name): ADVANCED SUPPORTED LIVING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20403 N LAKE PLEASANT RD SUITE 117-232
PEORIA AZ
85382-9702
US

IV. Provider business mailing address

20403 N LAKE PLEASANT RD SUITE 117-232
PEORIA AZ
85382-9702
US

V. Phone/Fax

Practice location:
  • Phone: 480-548-7446
  • Fax: 480-907-1744
Mailing address:
  • Phone: 480-548-7446
  • Fax: 480-907-1744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL JAMES CHURCHILL
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: RN
Phone: 480-548-7446