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General NPI Number Information
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NPI Number | 1639526635
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Entity Type | Organization
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Legal Business Name | HALLMARK ASSISTED LIVING @ WAGONER, LLC
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Dates
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Enumeration Date | 05/19/2016
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Last Update Date | 05/19/2016
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Provider Practice Location Address
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Address Line | 6127 W WAGONER RD
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City | GLENDALE
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State | AZ
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Zip | 85308-1150
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Country | US
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Telephone | 602-354-8941
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Fax |
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Provider Business Mailing Address
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Address Line | 4365 E PECOS RD STE 133
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City | GILBERT
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State | AZ
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Zip | 85295-8053
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JEFF TILLEY
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Credential |
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Telephone | 602-695-4156
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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 |
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License Number State |
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