Basic Information
| Provider Information | |||||||||
| NPI: | 1154541324 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHOENIX SENIOR LIVING LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WILLOW CREEK ASSISTED LIVING & MEMORY CARE COMMUNITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3006 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973020006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034858697 | ||||||||
| FaxNumber: | 5034851279 | ||||||||
| Practice Location | |||||||||
| Address1: | 12322 N 13TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | YOUNGTOWN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235832460 | ||||||||
| FaxNumber: | 5034851279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2007 | ||||||||
| LastUpdateDate: | 07/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | HARDER | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5034858697 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | ALC5613 | AZ | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 310400000X | ALC5613 | AZ | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.