MEDICARE: LIVE WELL ASSISTED LIVING

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	323P00000X	Psychiatric Residential Treatment Facility

General Provider Information

NPI Number	:	1942848627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVE WELL ASSISTED LIVING

Provider Business Mailing Address
First Line	:	4544 N 91ST DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85037-2449
Country	:	US
Telephone Number	:	623-399-7824
Fax Number	:

Provider Business Practice Location Address
First Line	:	4544 N 91ST DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85037-2449
Country	:	US
Telephone Number	:	623-399-7824
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	DESIRE RUSINGIZWA
Credential	:
Telephone Number	:	623-877-3764

Provider Enumeration Date	:	12/13/2019
Last Update Date	:	12/13/2019

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