Provider Demographics
NPI:1982464095
Name:1217 KENWOOD LLC
Entity type:Organization
Organization Name:1217 KENWOOD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:LADONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDGINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-646-2414
Mailing Address - Street 1:1217 E KENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203
Mailing Address - Country:US
Mailing Address - Phone:480-646-2414
Mailing Address - Fax:
Practice Address - Street 1:1217 E KENWOOD ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203
Practice Address - Country:US
Practice Address - Phone:480-646-2414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:1217 KENWOOD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-19
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility