Basic Information
| Provider Information | |||||||||
| NPI: | 1598018921 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOLDEN AGE SENIOR CARE OF CIELO VISTA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUNRIDGE AT CIELO VISTA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 S WACKER DR STE 1800 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606064313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3123571611 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7949 SUNMOUNT DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799254892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157724036 | ||||||||
| FaxNumber: | 9157722191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2012 | ||||||||
| LastUpdateDate: | 10/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3125217600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 133882 | TX | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.