=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922889047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE PINES AT PRESCOTT VALLEY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2023
-----------------------------------------------------
Last Update Date | 10/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3951 N VIEWPOINT DR
-----------------------------------------------------
City | PRESCOTT VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86314-2689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-888-6246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 HINES ST SE STE 190
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97302-1356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-401-9353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MR. RONALD ZIEBART
-----------------------------------------------------
Credential | N/A
-----------------------------------------------------
Telephone | 503-363-4636
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------