The Lodge at 14TH St.

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

Legal business name

THE LODGE AT 14TH ST.

Practice address

2941 N 14TH St
Phoenix, AZ 85014-5604

Phone

(602) 279-1033

Fax

(602) 277-5604

NPI assigned

Nov 30, 2005

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

John Garvey

Title

General Partner

Phone

(602) 279-1033

Specialties & licenses 3

Addresses

Other identifiers 2

Other names 1

• crystal lodge investors Former legal business name

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1133308800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1729641600000",
    "number": "1083698328",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2941 N. 14TH ST.",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850145604",
            "telephone_number": "602-279-1033",
            "fax_number": "602-277-5367"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2941 N 14TH ST",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850145604",
            "telephone_number": "602-279-1033",
            "fax_number": "602-277-5604"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE LODGE AT 14TH ST.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-11-30",
        "last_updated": "2024-10-23",
        "certification_date": "2024-10-23",
        "status": "A",
        "authorized_official_last_name": "GARVEY",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "GENERAL PARTNER",
        "authorized_official_telephone_number": "602-279-1033"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "AZ",
            "license": "ALC 4746",
            "primary": false
        },
        {
            "code": "282J00000X",
            "taxonomy_group": "",
            "desc": "Religious Nonmedical Health Care Institution",
            "state": "AZ",
            "license": "ALC-4746",
            "primary": false
        },
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "629-256",
            "state": "AZ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "629256",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "crystal lodge investors",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 23, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.