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General NPI Number Information
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NPI Number | 1164606620
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Entity Type | Organization
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Legal Business Name | VINEYARD ADULT CARE HOME
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Dates
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Enumeration Date | 12/19/2007
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Last Update Date | 01/29/2009
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Provider Practice Location Address
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Address Line | 4415 W CAROL AVE
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City | GLENDALE
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State | AZ
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Zip | 85302-3814
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Country | US
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Telephone | 623-847-1216
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Fax | 623-847-1216
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Provider Business Mailing Address
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Address Line | 4415 W CAROL AVE
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City | GLENDALE
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State | AZ
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Zip | 85302-3814
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Country | US
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Telephone | 623-847-1216
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Fax | 623-847-1216
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | CORNELIA LUPAS
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Credential |
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Telephone | 623-847-1216
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | ALH-6842
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License Number State | AZ
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