Basic Information
| Provider Information | |||||||||
| NPI: | 1649627423 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 19TH AVENUE OPERATIONS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE PALAZZO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 CORPORATE POINTE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902307690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103371929 | ||||||||
| FaxNumber: | 3108611661 | ||||||||
| Practice Location | |||||||||
| Address1: | 6246 N 19TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850151511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024336300 | ||||||||
| FaxNumber: | 6024336458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2016 | ||||||||
| LastUpdateDate: | 01/04/2017 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 3103371929 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL10014C | AZ | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 310400000X | AL10013C | AZ | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | NCI-2694 | AZ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.