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General NPI Number Information
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NPI Number | 1083698328
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Entity Type | Organization
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Legal Business Name | THE LODGE AT 14TH ST.
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Dates
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Enumeration Date | 11/30/2005
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Last Update Date | 10/23/2024
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Provider Practice Location Address
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Address Line | 2941 N 14TH ST
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City | PHOENIX
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State | AZ
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Zip | 85014-5604
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Country | US
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Telephone | 602-279-1033
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Fax | 602-277-5604
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Provider Business Mailing Address
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Address Line | 2941 N. 14TH ST.
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City | PHOENIX
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State | AZ
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Zip | 85014-5604
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Country | US
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Telephone | 602-279-1033
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Fax | 602-277-5367
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Authorized Official
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Title or Position | GENERAL PARTNER
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Name | JOHN GARVEY
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Credential |
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Telephone | 602-279-1033
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | ALC 4746
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 282J00000X
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Taxonomy Name | Religious Nonmedical Health Care Institution
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License Number | ALC-4746
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License Number State | AZ
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Taxonomy #3
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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