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General NPI Number Information
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NPI Number | 1114172053
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Entity Type | Organization
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Legal Business Name | SUPERSTITION MANOR ASSISTED LIVING LLC
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Dates
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Enumeration Date | 11/19/2008
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Last Update Date | 10/10/2013
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Provider Practice Location Address
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Address Line | 201 W 20TH AVE
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City | APACHE JUNCTION
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State | AZ
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Zip | 85220-7532
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Country | US
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Telephone | 480-288-9711
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Fax | 480-228-8869
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Provider Business Mailing Address
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Address Line | 201 W 20TH AVE
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City | APACHE JUNCTION
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State | AZ
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Zip | 85120-7532
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Country | US
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Telephone | 480-288-9711
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Fax | 480-288-8869
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Authorized Official
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Title or Position | OWNER MANAGER
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Name | MR. BRUCE BOGUCKI
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Credential |
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Telephone | 480-227-3458
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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