Provider Demographics
NPI:1992944151
Name:PONDEROSA PINES CARE AND REHAB, INC
Entity type:Organization
Organization Name:PONDEROSA PINES CARE AND REHAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SYSTEMS ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-296-5106
Mailing Address - Street 1:800 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7103
Mailing Address - Country:US
Mailing Address - Phone:928-779-6931
Mailing Address - Fax:928-779-2180
Practice Address - Street 1:800 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7103
Practice Address - Country:US
Practice Address - Phone:928-779-6931
Practice Address - Fax:928-779-2180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCI-340314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ707341Medicaid
AZ707341Medicaid