MEDICARE: MARA VILLA CARE CENTER, INC.

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	NCI2644	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992797294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARA VILLA CARE CENTER, INC.

Provider Business Mailing Address
First Line	:	PO BOX 155635
Second Line	:	STE 400
City	:	FORT WORTH
State	:	TX
Zip	:	76155-0635
Country	:	US
Telephone Number	:	817-359-2000
Fax Number	:	817-359-2093

Provider Business Practice Location Address
First Line	:	8825 S 7TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-7626
Country	:	US
Telephone Number	:	602-243-6121
Fax Number	:	602-276-7390

Authorized Official
Title or Position	:	CEO
Name	:	GARY R TREBERT
Credential	:
Telephone Number	:	817-359-2000

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	08/22/2020

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