Provider Demographics
NPI:1346088044
Name:SUPPORTIVE LIVING LLC
Entity type:Organization
Organization Name:SUPPORTIVE LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-977-9222
Mailing Address - Street 1:2240 S DON CARLOS
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-6307
Mailing Address - Country:US
Mailing Address - Phone:480-977-9222
Mailing Address - Fax:
Practice Address - Street 1:10432 W WEST WIND DR.
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383
Practice Address - Country:US
Practice Address - Phone:480-977-9222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility