Healthcare Provider Details

I. General information

NPI: 1083698328
Provider Name (Legal Business Name): THE LODGE AT 14TH ST.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2941 N 14TH ST
PHOENIX AZ
85014-5604
US

IV. Provider business mailing address

2941 N. 14TH ST.
PHOENIX AZ
85014-5604
US

V. Phone/Fax

Practice location:
  • Phone: 602-279-1033
  • Fax: 602-277-5604
Mailing address:
  • Phone: 602-279-1033
  • Fax: 602-277-5367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberALC 4746
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code282J00000X
TaxonomyReligious Nonmedical Health Care Institution
License NumberALC-4746
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: JOHN GARVEY
Title or Position: GENERAL PARTNER
Credential:
Phone: 602-279-1033