Provider Demographics
NPI:1730395757
Name:DARIENNE, LLC
Entity type:Organization
Organization Name:DARIENNE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LA WYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-428-0280
Mailing Address - Street 1:2150 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-2204
Mailing Address - Country:US
Mailing Address - Phone:928-348-3293
Mailing Address - Fax:
Practice Address - Street 1:2150 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-2204
Practice Address - Country:US
Practice Address - Phone:928-348-3293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1710225100000X
AZADH6049310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ178757Medicaid