Healthcare Provider Details

I. General information

NPI: 1558753533
Provider Name (Legal Business Name): GOLDEN LIFE ASSISTED LIVING HOME-1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2015
Last Update Date: 02/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4113 W HAYWARD AVE
PHOENIX AZ
85051-5751
US

IV. Provider business mailing address

4113 W HAYWARD AVE
PHOENIX AZ
85051-5751
US

V. Phone/Fax

Practice location:
  • Phone: 602-332-0780
  • Fax: 623-399-8915
Mailing address:
  • Phone: 602-332-0780
  • Fax: 623-399-8915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAL8880H
License Number StateAZ

VIII. Authorized Official

Name: REBECCA SIDDIQUI
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-332-0780