Provider Demographics
NPI:1447256466
Name:LIFESTREAM COMPLETE SENIOR LIVING INC.
Entity type:Organization
Organization Name:LIFESTREAM COMPLETE SENIOR LIVING INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-933-3333
Mailing Address - Street 1:11527 W PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGTOWN
Mailing Address - State:AZ
Mailing Address - Zip Code:85363-1640
Mailing Address - Country:US
Mailing Address - Phone:623-933-4683
Mailing Address - Fax:623-972-4993
Practice Address - Street 1:11527 W PEORIA AVE
Practice Address - Street 2:
Practice Address - City:YOUNGTOWN
Practice Address - State:AZ
Practice Address - Zip Code:85363-1640
Practice Address - Country:US
Practice Address - Phone:623-933-4683
Practice Address - Fax:623-972-4993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCI-382314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ010581OtherADVANTAGE BY BRIDGEWAY HEALTH SOLUTIONS
AZ0073850OtherBLUE CROSS BLUE SHIELD
AZ040311Medicaid
AZ0071-0000168OtherUNITEDHEALTHCARE NURSING HOME PLAN
AZ1025871OtherMERCY CARE ADVANTAGE
AZ040311Medicaid