Provider Demographics
NPI:1588155535
Name:RIVENDELL ENTERPRISES LLC
Entity type:Organization
Organization Name:RIVENDELL ENTERPRISES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RACQUEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-993-1596
Mailing Address - Street 1:1901 W JOAN DE ARC AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-1616
Mailing Address - Country:US
Mailing Address - Phone:602-993-1596
Mailing Address - Fax:602-993-1440
Practice Address - Street 1:1901 W JOAN DE ARC AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-1616
Practice Address - Country:US
Practice Address - Phone:602-993-1596
Practice Address - Fax:602-993-1440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL6401H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ959596Medicaid