Healthcare Provider Details

I. General information

NPI: 1497124465
Provider Name (Legal Business Name): DAMARIS ASSISTED LIVING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15243 W POST DR
SURPRISE AZ
85374-1424
US

IV. Provider business mailing address

15243 W POST DR
SURPRISE AZ
85374
US

V. Phone/Fax

Practice location:
  • Phone: 623-214-5342
  • Fax: 623-546-5904
Mailing address:
  • Phone: 623-214-5342
  • Fax: 623-546-5904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL8836H
License Number StateAZ

VIII. Authorized Official

Name: DAMARIS FANICA
Title or Position: OWNER
Credential:
Phone: 623-214-5342