Provider Demographics
NPI:1386101822
Name:ASSISTED SENIOR LIVING CARE, LLC
Entity type:Organization
Organization Name:ASSISTED SENIOR LIVING CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ISA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIADI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-985-4433
Mailing Address - Street 1:8550 S HARLEM AVE STE G
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60455-1775
Mailing Address - Country:US
Mailing Address - Phone:219-985-4433
Mailing Address - Fax:
Practice Address - Street 1:4149 E GREENWAY CIR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4036
Practice Address - Country:US
Practice Address - Phone:708-237-9000
Practice Address - Fax:708-237-1577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ473072Medicaid
AZ473403Medicaid