Basic Information
Provider Information
NPI: 1760577993
EntityType: 2
ReplacementNPI:  
OrganizationName: SPRINGDALE VILLAGE, INC.
LastName:  
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MiddleName:  
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Credential:  
OtherOrganizationName:  
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Mailing Information
Address1: 7255 E. BROADWAY RD.
Address2:  
City: MESA
State: AZ
PostalCode: 85208
CountryCode: US
TelephoneNumber: 4809818844
FaxNumber: 4809816998
Practice Location
Address1: 7255 E. BROADWAY RD.
Address2:  
City: MESA
State: AZ
PostalCode: 852089201
CountryCode: US
TelephoneNumber: 4809818844
FaxNumber: 4809816998
Other Information
ProviderEnumerationDate: 10/04/2006
LastUpdateDate: 08/22/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: CARLSON
AuthorizedOfficialFirstName: LINDA
AuthorizedOfficialMiddleName: L
AuthorizedOfficialTitleorPosition: CHIEF EXECUTIVE OFFICER
AuthorizedOfficialTelephone: 4809818844
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
310400000XALC-4861AZY Nursing & Custodial Care FacilitiesAssisted Living Facility 

ID Information
IDTypeStateIssuerDescription
52731905AZ MEDICAID


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