Provider Demographics
NPI:1861876500
Name:ST CHARLES PLACE
Entity type:Organization
Organization Name:ST CHARLES PLACE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:602-276-0084
Mailing Address - Street 1:6818 S 16TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-5714
Mailing Address - Country:US
Mailing Address - Phone:602-276-0084
Mailing Address - Fax:602-595-9969
Practice Address - Street 1:6818 S 16TH PL
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-5714
Practice Address - Country:US
Practice Address - Phone:602-276-0084
Practice Address - Fax:602-595-9969
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST CHARLES PLACE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL3064H310400000X
AZAL 8954H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ426933Medicaid