Basic Information
| Provider Information | |||||||||
| NPI: | 1790908689 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERITUS PROPERTIES NGH, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROOKDALE NORTH MESA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6737 W WASHINGTON ST | ||||||||
| Address2: | SUITE 2300 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532145647 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2122 EAST BROWN ROAD | ||||||||
| Address2: | |||||||||
| City: | MASA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852135200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062982909 | ||||||||
| FaxNumber: | 2063014500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | RICHARDSON | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EVP, CHIEF ADMIN. OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6155648131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | ALC4036 | AZ | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 310400000X | ALC-4036 | AZ | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 700122 | 05 | AZ | MEDICAID |