Provider Demographics
NPI:1699342360
Name:GIBSON LANE ASSISTED LIVING LLC
Entity type:Organization
Organization Name:GIBSON LANE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEBATU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-384-8495
Mailing Address - Street 1:8011 W GIBSON LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-7484
Mailing Address - Country:US
Mailing Address - Phone:602-384-8495
Mailing Address - Fax:
Practice Address - Street 1:8011 W GIBSON LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043-7484
Practice Address - Country:US
Practice Address - Phone:602-384-8495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility