Healthcare Provider Details

I. General information

NPI: 1457471468
Provider Name (Legal Business Name): DESERT AMETHYST RETIREMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2007
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18170 N 91ST AVENUE
PEORIA AZ
85382-0866
US

IV. Provider business mailing address

PO BOX 3006
SALEM OR
97302-0006
US

V. Phone/Fax

Practice location:
  • Phone: 623-974-5848
  • Fax:
Mailing address:
  • Phone: 503-375-9016
  • Fax: 503-485-1279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberALC4691
License Number StateAZ

VIII. Authorized Official

Name: MR. JON M HARDER
Title or Position: MANAGER
Credential:
Phone: 503-375-9016