Basic Information
Provider Information | |||||||||
NPI: | 1942471057 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PINNACLE HEALTH FACILITIES XXVI LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MESA CHRISTIAN RESIDENTIAL CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5420 W PLANO PKWY | ||||||||
Address2: |   | ||||||||
City: | PLANO | ||||||||
State: | TX | ||||||||
PostalCode: | 750934823 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9729313800 | ||||||||
FaxNumber: | 9719308191 | ||||||||
Practice Location | |||||||||
Address1: | 215 W BROWN RD | ||||||||
Address2: |   | ||||||||
City: | MESA | ||||||||
State: | AZ | ||||||||
PostalCode: | 852013415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4806686118 | ||||||||
FaxNumber: | 4804611552 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/17/2008 | ||||||||
LastUpdateDate: | 08/21/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COLLIER | ||||||||
AuthorizedOfficialFirstName: | JAMIE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
AuthorizedOfficialTelephone: | 9729313800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X |   |   | Y |   | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
ID | Type | State | Issuer | Description | 353066 | 05 | AZ |   | MEDICAID |