Basic Information
| Provider Information | |||||||||
| NPI: | 1780719039 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRESTIGE ASSISTED LIVING AT CLAREMONT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 CLAREMONT DR | ||||||||
| Address2: | |||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864068684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288554843 | ||||||||
| FaxNumber: | 9288552987 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 CLAREMONT DR | ||||||||
| Address2: | |||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864068684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288554843 | ||||||||
| FaxNumber: | 9288552987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 07/07/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROACH | ||||||||
| AuthorizedOfficialFirstName: | ERICA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 9288554843 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 07-00003187 | AZ | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.