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General NPI Number Information
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NPI Number | 1386971877
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Entity Type | Organization
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Legal Business Name | LDRKAIR
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Dates
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Enumeration Date | 11/04/2009
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Last Update Date | 11/04/2009
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Provider Practice Location Address
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Address Line | 395 W GARDEN LN
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City | SNOWFLAKE
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State | AZ
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Zip | 85937-6218
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Country | US
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Telephone | 928-536-7935
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Fax | 928-536-5444
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Provider Business Mailing Address
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Address Line | 395 W GARDEN LN
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City | SNOWFLAKE
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State | AZ
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Zip | 85937-6218
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Country | US
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Telephone | 928-536-7935
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Fax | 928-536-5444
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Authorized Official
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Title or Position | OWNER
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Name | MR. LARRY DOUGLAS MATYAS
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Credential |
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Telephone | 928-536-7935
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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 | ALC-4533
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License Number State | AZ
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