Provider Demographics
NPI:1386940401
Name:PASTALINO MANOR LLC
Entity type:Organization
Organization Name:PASTALINO MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KIVILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-236-4717
Mailing Address - Street 1:1383 W KESLER LN
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-7289
Mailing Address - Country:US
Mailing Address - Phone:480-634-5485
Mailing Address - Fax:480-634-5485
Practice Address - Street 1:1383 W KESLER LN
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-7289
Practice Address - Country:US
Practice Address - Phone:480-634-5485
Practice Address - Fax:480-634-5485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3710320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH-3710OtherAZ DEPT. OF HEALTH OBHL LICENSE NUMBER