Provider Demographics
NPI:1548637820
Name:KING ASSISTED LIVING LLC
Entity type:Organization
Organization Name:KING ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KINGA
Authorized Official - Middle Name:A
Authorized Official - Last Name:TOMOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-820-9498
Mailing Address - Street 1:3318 E MARCONI AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3865
Mailing Address - Country:US
Mailing Address - Phone:602-820-9498
Mailing Address - Fax:602-535-4888
Practice Address - Street 1:3424 E MONTE CRISTO AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3800
Practice Address - Country:US
Practice Address - Phone:602-820-9498
Practice Address - Fax:602-535-4888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL9443H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherAHCCCS PROVIDER NR. 986802