Provider Demographics
NPI:1174094338
Name:RADIANT CARE HOME
Entity type:Organization
Organization Name:RADIANT CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BONTILAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-293-1396
Mailing Address - Street 1:15174 W BOCA RATON RD
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-8005
Mailing Address - Country:US
Mailing Address - Phone:623-518-4534
Mailing Address - Fax:623-518-4534
Practice Address - Street 1:15174 W BOCA RATON RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-8005
Practice Address - Country:US
Practice Address - Phone:623-518-4534
Practice Address - Fax:623-518-4534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ000000000000Medicaid
00000000000OtherN/A