Provider Demographics
NPI:1215096516
Name:JOLLEY FAMILY ASSISTED LIVING HOME
Entity type:Organization
Organization Name:JOLLEY FAMILY ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FAY
Authorized Official - Middle Name:ESTER
Authorized Official - Last Name:JOLLEY-WEBSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-327-0995
Mailing Address - Street 1:20110 W BROADWAY RD
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-5753
Mailing Address - Country:US
Mailing Address - Phone:623-386-2201
Mailing Address - Fax:623-386-0189
Practice Address - Street 1:20106 W BROADWAY RD
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-5753
Practice Address - Country:US
Practice Address - Phone:623-327-0995
Practice Address - Fax:623-327-0996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH 2643310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ529951Medicaid