Provider Demographics
NPI:1104315126
Name:AC ASSISTED LIVING
Entity type:Organization
Organization Name:AC ASSISTED LIVING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIKE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:480-203-5862
Mailing Address - Street 1:3907 W. LANE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-5754
Mailing Address - Country:US
Mailing Address - Phone:623-547-7232
Mailing Address - Fax:623-215-2341
Practice Address - Street 1:3907 W. LANE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-5754
Practice Address - Country:US
Practice Address - Phone:623-547-7232
Practice Address - Fax:623-215-2341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-04
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10714H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAL11475HOtherAZ DEPARTMENT OF HEALTH SERVICES