Basic Information
| Provider Information | |||||||||
| NPI: | 1902028145 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMERITUS CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | EMERITUS AT OLIVE GROVE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 ELLIOTT AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981211044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062982909 | ||||||||
| FaxNumber: | 2063014500 | ||||||||
| Practice Location | |||||||||
| Address1: | 3014 E INDIAN SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850166887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029577021 | ||||||||
| FaxNumber: | 6029570830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 05/03/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BICKEL | ||||||||
| AuthorizedOfficialFirstName: | NOELLE | ||||||||
| AuthorizedOfficialMiddleName: | DIAZ | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2062982909 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 311500000X | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 310400000X | ALC-P-4752 | AZ | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | ALC-4752 | 05 | AZ | MEDICAID |