Basic Information
| Provider Information | |||||||||
| NPI: | 1679515449 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHERN ARIZONA SENIOR LIVING COMMUNITY, L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | THE PEAKS HEALTH & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1107 HAZELTINE BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHASKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553181009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9523618000 | ||||||||
| FaxNumber: | 9523618060 | ||||||||
| Practice Location | |||||||||
| Address1: | 3150 N WINDING BROOK RD | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860010972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287747106 | ||||||||
| FaxNumber: | 9282130831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 02/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENSON | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9523618000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | ALC-2517 | AZ | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | NCI-2515 | AZ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 504698 | 01 | HEALTH CHOICE ARIZONA | OTHER | 504698 | 01 | MERCY CARE PLAN | OTHER | 504698 | 05 | AZ | MEDICAID | 504698 | 01 | IHS-FFS | OTHER | AZ0206980 | 01 | AZ | BCBS OF AZ MANAGED CARE | OTHER | 504698 | 01 | EVERCARE SELECT | OTHER | 582230 | 05 | AZ | MEDICAID |