Provider Demographics
NPI:1548505357
Name:HOLBROOK SENIOR CITIZENS ASSOCIATION
Entity type:Organization
Organization Name:HOLBROOK SENIOR CITIZENS ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-524-2344
Mailing Address - Street 1:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:AZ
Mailing Address - Zip Code:86025
Mailing Address - Country:US
Mailing Address - Phone:928-524-2344
Mailing Address - Fax:928-524-3603
Practice Address - Street 1:216 JOY NEVIN AVENUE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025
Practice Address - Country:US
Practice Address - Phone:928-524-2344
Practice Address - Fax:928-524-3603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL0054C310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ829731OtherAHCCCS PROVIDER NUMBER