Organization
LDRKAIR
Active
Other names
The Carriage House on West Garden Lane
Organization subpart
No
Provider details
NPI number
Authorized official
MR. LARRY DOUGLAS MATYAS (OWNER)
(928) 536-7935
Entity
Organization
Contact information
Practice address
395 W GARDEN LN, SNOWFLAKE, AZ 85937-6218
(928) 536-7935
(928) 536-5444
Mailing address
395 W GARDEN LN, SNOWFLAKE, AZ 85937-6218
(928) 536-7935
(928) 536-5444
Taxonomy
Speciality
Code
Description
License number
State
311ZA0620X
Adult Care Home Facility
Primary
ALC-4533
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
28275659
EVERCARE PROVIDER CAREONE ID
AZ
01
—
EVC6003704
EVERCARE PROVIDER SUBSCRIBER ID
AZ
Enumeration date
11/04/2009
Last updated
11/04/2009
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