Basic Information
| Provider Information | |||||||||
| NPI: | 1942736582 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VENTANA WINDS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12322 N 113TH AVE | ||||||||
| Address2: | |||||||||
| City: | YOUNGTOWN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853631268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235832460 | ||||||||
| FaxNumber: | 6235834677 | ||||||||
| Practice Location | |||||||||
| Address1: | 12322 N 113TH AVE | ||||||||
| Address2: | |||||||||
| City: | YOUNGTOWN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853631268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235832460 | ||||||||
| FaxNumber: | 6235834677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2017 | ||||||||
| LastUpdateDate: | 05/02/2017 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | MELBA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6235832460 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL8153C | AZ | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 541617 | 05 | AZ | MEDICAID |