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General NPI Number Information
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NPI Number | 1285946475
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Entity Type | Organization
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Legal Business Name | PROVIDENCE LEGACY ASSISTED LIVING
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Dates
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Enumeration Date | 07/06/2010
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Last Update Date | 07/06/2010
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Provider Practice Location Address
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Address Line | 4812 E MEADOW MIST LN
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City | QUEEN CREEK
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State | AZ
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Zip | 85140-5222
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Country | US
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Telephone | 480-388-1151
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Fax |
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Provider Business Mailing Address
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Address Line | 4812 E MEADOW MIST LN
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City | QUEEN CREEK
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State | AZ
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Zip | 85140-5222
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | JINETTE LANOIX
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Credential |
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Telephone | 480-388-1151
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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 | AL7937
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License Number State | AZ
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