Provider Demographics
NPI:1558154559
Name:ESTANCIA ASSISTED LIVING AT AVOCA PLACE, LLC
Entity type:Organization
Organization Name:ESTANCIA ASSISTED LIVING AT AVOCA PLACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-561-5590
Mailing Address - Street 1:16543 E ELGIN ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-2003
Mailing Address - Country:US
Mailing Address - Phone:480-561-5590
Mailing Address - Fax:409-908-4682
Practice Address - Street 1:2237 N AVOCA
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-2028
Practice Address - Country:US
Practice Address - Phone:480-561-5590
Practice Address - Fax:409-908-4682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ177782Medicaid