Provider Demographics
NPI:1174247332
Name:EL MIRAGE GROUP HOME LLC
Entity type:Organization
Organization Name:EL MIRAGE GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CORNELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-694-5101
Mailing Address - Street 1:13045 W PORT ROYALE LN
Mailing Address - Street 2:
Mailing Address - City:EL MIRAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85335-3428
Mailing Address - Country:US
Mailing Address - Phone:623-694-5101
Mailing Address - Fax:
Practice Address - Street 1:13045 W PORT ROYALE LN
Practice Address - Street 2:
Practice Address - City:EL MIRAGE
Practice Address - State:AZ
Practice Address - Zip Code:85335-3428
Practice Address - Country:US
Practice Address - Phone:623-694-5101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility