MEDICARE: ALPINE VILLA 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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1598282535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALPINE VILLA LLC

Provider Business Mailing Address
First Line	:	6439 W WILLOW AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85304-1050
Country	:	US
Telephone Number	:	602-292-2010
Fax Number	:

Provider Business Practice Location Address
First Line	:	3530 W CARIBBEAN LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85053-4635
Country	:	US
Telephone Number	:	602-583-7370
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ERIC MAUGHAN
Credential	:
Telephone Number	:	602-292-2010

Provider Enumeration Date	:	08/29/2017
Last Update Date	:	01/16/2024

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