Provider Demographics
NPI:1386726222
Name:SENIOR LIVING OPTIONS MARYLAND GARDENS, LLC
Entity type:Organization
Organization Name:SENIOR LIVING OPTIONS MARYLAND GARDENS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOCKBEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-265-7484
Mailing Address - Street 1:31 W MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-1227
Mailing Address - Country:US
Mailing Address - Phone:602-265-7484
Mailing Address - Fax:602-265-0659
Practice Address - Street 1:31 W MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-1227
Practice Address - Country:US
Practice Address - Phone:602-265-7484
Practice Address - Fax:602-265-0659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALC5942311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ160139Medicaid