=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386519205
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE HERITAGE AT PALM PARKE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2025
-----------------------------------------------------
Last Update Date | 10/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1745 N PALM PARKE BLVD
-----------------------------------------------------
City | CASA GRANDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85122-6700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-476-5181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1745 N PALM PARKE BLVD
-----------------------------------------------------
City | CASA GRANDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85122-6700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DISHON KARIUKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-476-5181
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------