Healthcare Provider Details

I. General information

NPI: 1184947418
Provider Name (Legal Business Name): LSREF GOLDEN OPS UE (AZ), LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 03/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18172 N 91ST AVE
PEORIA AZ
85382-3001
US

IV. Provider business mailing address

500 STEVENS AVE
SOLANA BEACH CA
92075-2055
US

V. Phone/Fax

Practice location:
  • Phone: 623-974-5847
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: WICK PETERSON
Title or Position: VP
Credential:
Phone: 858-436-7662