Basic Information
| Provider Information | |||||||||
| NPI: | 1356656193 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERICARE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROOKDALE CHRISTOWN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6737 W. WASHINGTON STREET | ||||||||
| Address2: | SUITE 2300 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532145650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149185000 | ||||||||
| FaxNumber: | 4149185050 | ||||||||
| Practice Location | |||||||||
| Address1: | 6246 N 19TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850151511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024336300 | ||||||||
| FaxNumber: | 6024336218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2010 | ||||||||
| LastUpdateDate: | 03/25/2015 | ||||||||
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| AuthorizedOfficialLastName: | OHLENDORF | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CFO, DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4149185000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NCI-2693 | AZ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 592143 | 05 | AZ | MEDICAID |