Healthcare Provider Details

I. General information

NPI: 1255147146
Provider Name (Legal Business Name): TRUSTED CARE ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 S 6TH ST
PHOENIX AZ
85040-2216
US

IV. Provider business mailing address

11207 W KANSAS AVE
YOUNGTOWN AZ
85363-1527
US

V. Phone/Fax

Practice location:
  • Phone: 602-726-1001
  • 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
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MARYAH WILLIAMS
Title or Position: OWNER
Credential:
Phone: 602-726-1001