Provider Demographics
NPI:1063142644
Name:AVONDALE ASSISTED LIVING HOME
Entity type:Organization
Organization Name:AVONDALE ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MA TERESITA
Authorized Official - Middle Name:PATINO
Authorized Official - Last Name:ISIDERIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-343-8045
Mailing Address - Street 1:13514 W MONTEREY WAY
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-6792
Mailing Address - Country:US
Mailing Address - Phone:480-343-8045
Mailing Address - Fax:
Practice Address - Street 1:13514 W MONTEREY WAY
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-6792
Practice Address - Country:US
Practice Address - Phone:480-343-8045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility