# POPS PROVISIONAL PLACE LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1952820557
- **Authorized official:** MRS. MARCIA DIANNE CRAYTON LPN (ADMINISTRATOR)
- **Authorized official phone:** (623) 693-3112

## Contact information

- **Practice address:** 29741 W AMELIA AVE, BUCKEYE, AZ 85396-7169
- **Practice address phone:** (623) 693-3112
- **Practice address fax:** (623) 434-3882
- **Mailing address:** 29741 W AMELIA AVE, BUCKEYE, AZ 85396-7169
- **Mailing address phone:** (623) 693-3112
- **Mailing address fax:** (623) 434-3882

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 164W00000X | Licensed Practical Nurse | 044613 | AZ | Yes |

## Other

- **Enumeration date:** 09/14/2017
- **Last updated:** 07/21/2022