Provider Demographics
NPI:1992096101
Name:ASANTE TRC OF SURPRISE LLC
Entity type:Organization
Organization Name:ASANTE TRC OF SURPRISE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-201-8356
Mailing Address - Street 1:14775 W. YORKSHIRE DR.
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7213
Mailing Address - Country:US
Mailing Address - Phone:623-594-5050
Mailing Address - Fax:623-594-5074
Practice Address - Street 1:14775 W. YORKSHIRE DR.
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7213
Practice Address - Country:US
Practice Address - Phone:623-594-5050
Practice Address - Fax:623-594-5074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ035282Medicare Oscar/Certification