Provider Demographics
NPI:1215311238
Name:SIONGCO, IMELDA
Entity type:Individual
Prefix:
First Name:IMELDA
Middle Name:
Last Name:SIONGCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 N SAGUARO ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-4283
Mailing Address - Country:US
Mailing Address - Phone:480-600-6818
Mailing Address - Fax:
Practice Address - Street 1:1432 N. DE SOTO ST.
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-7850
Practice Address - Country:US
Practice Address - Phone:480-755-4390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL9060311ZA0620X
AZAL8867311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ825596Medicaid
AZ825613Medicaid