Organization
HACIENDA SKILLED NURSING FACILITY
Active
Organization
HACIENDA SKILLED NURSING FACILITY
Active
Other names
Hacienda SNF Transport
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DALE NORMAN SKURDAHL (CHIEF OPERATING OFFICER)
(602) 243-4231
Entity
Organization
Contact information
Practice address
1402 E SOUTH MOUNTAIN AVE, PHOENIX, AZ 85042-7925
(602) 243-4231
(602) 323-5988
Mailing address
1402 E SOUTH MOUNTAIN AVE, PHOENIX, AZ 85042-7925
(602) 243-4231
(602) 323-5988
Taxonomy
Speciality
Code
Description
License number
State
3140N1450X
Pediatric Skilled Nursing Facility
LTC 0195
AZ
343900000X
Non-emergency Medical Transport (VAN)
Primary
LTC 0195
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
03D1096517
CLIA
AZ
05
—
544032
—
AZ
01
—
LTC 0195
STATE LICENSE
AZ
Enumeration date
08/27/2009
Last updated
08/27/2009
Update your record
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