Provider Demographics
NPI:1285946475
Name:PROVIDENCE LEGACY ASSISTED LIVING
Entity type:Organization
Organization Name:PROVIDENCE LEGACY ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LANOIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-388-1151
Mailing Address - Street 1:4812 E MEADOW MIST LN
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-5222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4812 E MEADOW MIST LN
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85140-5222
Practice Address - Country:US
Practice Address - Phone:480-388-1151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL7937310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility