Provider Demographics
NPI:1902899933
Name:PHOENIX MOUNTAIN NURSING CENTER INC
Entity type:Organization
Organization Name:PHOENIX MOUNTAIN NURSING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT TREASURER CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:C
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:HARKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-734-0533
Mailing Address - Street 1:13232 N TATUM BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032
Mailing Address - Country:US
Mailing Address - Phone:602-996-5200
Mailing Address - Fax:602-996-6160
Practice Address - Street 1:13232 N TATUM BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-6459
Practice Address - Country:US
Practice Address - Phone:602-996-5200
Practice Address - Fax:602-996-6160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNC1326314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ447228Medicaid
AZAZ0402260OtherBLUE CROSS BLUE SHIELD
4307000MOtherCIGNA HEALTH CARR OF AZ
1298610001OtherDMERC
1298610001OtherDMERC
AZ447228Medicaid