Provider Demographics
NPI:1053869123
Name:MRSC AZ MESA MASTER TENANT, LLC
Entity type:Organization
Organization Name:MRSC AZ MESA MASTER TENANT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGENDOEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-796-8700
Mailing Address - Street 1:537 S HIGLEY RD BLDG 2
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2148
Mailing Address - Country:US
Mailing Address - Phone:480-247-9880
Mailing Address - Fax:
Practice Address - Street 1:537 S HIGLEY RD BLDG 2
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2148
Practice Address - Country:US
Practice Address - Phone:480-247-9880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-16
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10067C310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ149133Medicaid
AZ149278Medicaid