MEDICARE: PLATINUM ASSISTED CARE

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	310400000X	Assisted Living Facility	ALH - 5208	AZ

General Provider Information

NPI Number	:	1831392455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLATINUM ASSISTED CARE

Provider Business Mailing Address
First Line	:	7041 W WILLOW AVE
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85381-5084
Country	:	US
Telephone Number	:	623-221-1544
Fax Number	:	623-334-3289

Provider Business Practice Location Address
First Line	:	3755 E MENLO ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85215-1717
Country	:	US
Telephone Number	:	623-221-1544
Fax Number	:	623-334-3289

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. DENEEN MARIE DE VRIES
Credential	:	PT, MBA
Telephone Number	:	623-221-1544

Provider Enumeration Date	:	06/10/2007
Last Update Date	:	01/17/2009

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Directions to “PLATINUM ASSISTED CARE ” Practice Location

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