Healthcare Provider Details

I. General information

NPI: 1386726222
Provider Name (Legal Business Name): SENIOR LIVING OPTIONS MARYLAND GARDENS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 W MARYLAND AVE
PHOENIX AZ
85013-1227
US

IV. Provider business mailing address

31 W MARYLAND AVE
PHOENIX AZ
85013-1227
US

V. Phone/Fax

Practice location:
  • Phone: 602-265-7484
  • Fax: 602-265-0659
Mailing address:
  • Phone: 602-265-7484
  • Fax: 602-265-0659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberALC5942
License Number StateAZ

VIII. Authorized Official

Name: SEAN MOCKBEE
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-265-7484