Provider Demographics
NPI:1972388999
Name:ARIZONA LIGHTHOUSE ASSISTED LIVING LLC
Entity type:Organization
Organization Name:ARIZONA LIGHTHOUSE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BENNIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HARGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-249-1119
Mailing Address - Street 1:13530 W TUCKEY CT
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85307-2067
Mailing Address - Country:US
Mailing Address - Phone:623-249-1119
Mailing Address - Fax:
Practice Address - Street 1:13530 W TUCKEY CT
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85307-2067
Practice Address - Country:US
Practice Address - Phone:623-249-1119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251G00000XAgenciesHospice Care, Community Based
No251S00000XAgenciesCommunity/Behavioral Health
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances