Provider Demographics
NPI:1679515449
Name:NORTHERN ARIZONA SENIOR LIVING COMMUNITY, L.L.C.
Entity type:Organization
Organization Name:NORTHERN ARIZONA SENIOR LIVING COMMUNITY, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-361-8000
Mailing Address - Street 1:1107 HAZELTINE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1009
Mailing Address - Country:US
Mailing Address - Phone:952-361-8000
Mailing Address - Fax:952-361-8060
Practice Address - Street 1:3150 N WINDING BROOK RD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-0972
Practice Address - Country:US
Practice Address - Phone:928-774-7106
Practice Address - Fax:928-213-0831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALC-2517310400000X
AZNCI-2515314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
504698OtherHEALTH CHOICE ARIZONA
504698OtherMERCY CARE PLAN
AZ504698Medicaid
504698OtherIHS-FFS
AZAZ0206980OtherBCBS OF AZ MANAGED CARE
504698OtherEVERCARE SELECT
AZ582230Medicaid
504698OtherEVERCARE SELECT
AZ035257Medicare Oscar/Certification