Provider Demographics
NPI:1386619799
Name:CASA DE LA LUZ LLC
Entity type:Organization
Organization Name:CASA DE LA LUZ LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER, LLC
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:C
Authorized Official - Last Name:POORE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, MBA
Authorized Official - Phone:520-544-9890
Mailing Address - Street 1:7740 N ORACLE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-6390
Mailing Address - Country:US
Mailing Address - Phone:520-544-9890
Mailing Address - Fax:520-544-9894
Practice Address - Street 1:7740 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-6390
Practice Address - Country:US
Practice Address - Phone:520-544-9890
Practice Address - Fax:520-544-9894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHSPC2206251G00000X
AZHSPC3560315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
No251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ483149Medicaid
AZ483149Medicaid