Healthcare Provider Details

I. General information

NPI: 1447256466
Provider Name (Legal Business Name): LIFESTREAM COMPLETE SENIOR LIVING INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11527 W PEORIA AVE
YOUNGTOWN AZ
85363-1640
US

IV. Provider business mailing address

11527 W PEORIA AVE
YOUNGTOWN AZ
85363-1640
US

V. Phone/Fax

Practice location:
  • Phone: 623-933-4683
  • Fax: 623-972-4993
Mailing address:
  • Phone: 623-933-4683
  • Fax: 623-972-4993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNCI-382
License Number StateAZ

VIII. Authorized Official

Name: MR. RONALD ESTES
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 623-933-3333