Provider Demographics
NPI:1902953813
Name:VILLA MARIA CARE CENTER, LLC
Entity Type:Organization
Organization Name:VILLA MARIA CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-991-9062
Mailing Address - Street 1:4310 E GRANT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2607
Mailing Address - Country:US
Mailing Address - Phone:520-323-9351
Mailing Address - Fax:
Practice Address - Street 1:4310 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2607
Practice Address - Country:US
Practice Address - Phone:602-368-8203
Practice Address - Fax:602-368-8211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALC4564310400000X
AZNCI263314000000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ618324Medicaid
AZ566292Medicaid
AZ035147Medicare ID - Type UnspecifiedNORIDIAN MEDICARE