Basic Information
| Provider Information | |||||||||
| NPI: | 1770664641 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWESTERN MEDICAL CENTERS-AZ, INC. | ||||||||
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| OtherOrganizationName: | PEPPERTREE ASSISTED LIVING APARTMENTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 NE LOOP 410 | ||||||||
| Address2: | SUITE 640 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782091204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108285686 | ||||||||
| FaxNumber: | 2108244669 | ||||||||
| Practice Location | |||||||||
| Address1: | 860 DOUGHERTY ST | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863051841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287789777 | ||||||||
| FaxNumber: | 9287170587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | STUDER | ||||||||
| AuthorizedOfficialFirstName: | STAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2108285686 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | ALC-4785 | AZ | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 500993 | 01 | AZ | ACCESS # | OTHER |