=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366741225
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SLO AUSTIN HOUSE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2011
-----------------------------------------------------
Last Update Date | 03/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 195 S WILLARD ST
-----------------------------------------------------
City | COTTONWOOD
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86326-4123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-634-4278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 195 S WILLARD ST
-----------------------------------------------------
City | COTTONWOOD
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86326-4123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-634-4278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JANYA RICCA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-634-4278
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL8288C
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------