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General NPI Number Information
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NPI Number | 1568758795
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Entity Type | Organization
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Legal Business Name | LAKESHORE CREST,LLC
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Dates
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Enumeration Date | 06/27/2011
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Last Update Date | 03/12/2012
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Provider Practice Location Address
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Address Line | 19535 N 55TH DR
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City | GLENDALE
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State | AZ
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Zip | 85308-6805
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Country | US
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Telephone | 623-376-6469
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Fax |
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Provider Business Mailing Address
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Address Line | 19535 N 55TH DR
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City | GLENDALE
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State | AZ
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Zip | 85308-6805
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Country | US
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Telephone | 623-376-6469
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MARIAFE SANTOS CASTRO
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Credential |
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Telephone | 480-518-1969
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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 | AL8496H
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License Number State | AZ
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