MEDICARE: PARK WAVERLY HEALTHCARE 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	314000000X	Skilled Nursing Facility	NCI-2639	AZ

General Provider Information

NPI Number	:	1629079975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK WAVERLY HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	2001 NORTH PARK AVENUE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85719-3558
Country	:	US
Telephone Number	:	520-882-6151
Fax Number	:	520-620-1547

Provider Business Practice Location Address
First Line	:	2001 NORTH PARK AVENUE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85719-3558
Country	:	US
Telephone Number	:	520-882-6151
Fax Number	:	520-620-1547

Authorized Official
Title or Position	:	AUTHORIZED AGENT
Name	:	MS. SOON BURNAM
Credential	:
Telephone Number	:	949-540-1249

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	02/16/2021

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