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General NPI Number Information
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NPI Number | 1487054292
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Entity Type | Organization
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Legal Business Name | STEVENS ASISTED LIVING HOME
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Dates
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Enumeration Date | 08/28/2014
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Last Update Date | 08/28/2014
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Provider Practice Location Address
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Address Line | 871 THUNDERBOLT AVE
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86406-7803
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Country | US
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Telephone | 928-453-2282
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Fax |
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Provider Business Mailing Address
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Address Line | 871 THUNDERBOLT AVE
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86406-7803
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Country | US
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Telephone | 928-453-2282
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CLARA ANN STEVENS
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Credential |
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Telephone | 928-453-2282
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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 | 1400030820
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License Number State | AZ
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