Provider Demographics
NPI:1679088504
Name:SUMMERHAVEN ASSISTED LIVING HOME LLC
Entity type:Organization
Organization Name:SUMMERHAVEN ASSISTED LIVING HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-621-6337
Mailing Address - Street 1:3118 W T RYAN LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-5216
Mailing Address - Country:US
Mailing Address - Phone:602-621-6337
Mailing Address - Fax:602-601-7727
Practice Address - Street 1:3118 W T RYAN LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-5216
Practice Address - Country:US
Practice Address - Phone:602-621-6337
Practice Address - Fax:602-601-7727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10582F310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility