Provider Demographics
NPI:1447918990
Name:NICOLETTE ASSISTED LIVING LLC
Entity type:Organization
Organization Name:NICOLETTE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:DE JESUS
Authorized Official - Last Name:SONGCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-347-8715
Mailing Address - Street 1:8559 W BROWN ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-3147
Mailing Address - Country:US
Mailing Address - Phone:480-347-8715
Mailing Address - Fax:
Practice Address - Street 1:8559 W BROWN ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-3147
Practice Address - Country:US
Practice Address - Phone:480-347-8715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ080410Medicaid