MEDICARE: ADAGIO LUXURY 4 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3104A0625X	Assisted Living Facility (Mental Illness)	AL10804H	AZ
2	385H00000X	Respite Care	AL10804H	AZ
3	310400000X	Assisted Living Facility	AL10804H	AZ

General Provider Information

NPI Number	:	1225510118
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADAGIO LUXURY 4 LLC

Provider Business Mailing Address
First Line	:	1045 E BETHANY HOME RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-2229
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1045 E BETHANY HOME RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-2229
Country	:	US
Telephone Number	:	602-803-9929
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MISS ANCA MICU
Credential	:
Telephone Number	:	602-803-9929

Provider Enumeration Date	:	09/06/2018
Last Update Date	:	09/06/2018

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Directions to “ADAGIO LUXURY 4 LLC ” Practice Location

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