NPIMap

Organization Active NPI

Park Waverly Healthcare LLC

Doing business as Park Avenue Health and Rehabilitaion Center

  • Skilled Nursing Facility
  • Tucson, AZ
National Provider Identifier
1629079975
Registry record updated Feb 16, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
NCI-2639 Issued in AZ
Legal business name
PARK WAVERLY HEALTHCARE LLC
Doing business as
Park Avenue Health and Rehabilitaion Center
Practice address
2001 North Park Avenue
Tucson, AZ 85719-3558
Phone
(520) 882-6151
Fax
(520) 620-1547
NPI assigned
Aug 9, 2005
Last updated
Feb 16, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 16, 2021

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

Authorized official

Name
Ms. Soon Burnam
Title
Authorized Agent
Phone
(949) 540-1249

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X NCI-2639 AZ Primary

Addresses

Primary practice location

2001 North Park Avenue
Tucson, AZ 85719-3558

Mailing address

2001 North Park Avenue
Tucson, AZ 85719-3558
Phone (520) 882-6151

Other names 1

  • Park Avenue Health and Rehabilitaion Center Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service Other eSolutions Inc.

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20030804000036 AZ Part A Provider - Skilled Nursing Facility 5395656011 Practice locations: Tucson, AZ

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1629079975. Details of each certification follow.

Skilled nursing facility certification: CCN 035174

Legal name
PARK WAVERLY HEALTHCARE LLC
Doing business as
PARK AVENUE HEALTH AND REHABILITATION CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Aug 3, 1988
Last certification
May 19, 2023
Beds
200
Ownership / control type
Limited Liability Corporation
Organization structure
LLCProprietary
Incorporated
Jul 11, 2003 in NV
Enrollment address
2001 N Park Ave
Tucson, AZ 85719-3558
Nursing home name
PARK AVENUE HEALTH AND REHABILITATION CENTER
Affiliated entity
THE ENSIGN GROUP

Care Compare: Nursing home

Medicare Care Compare
Listed as
Park Avenue Health and Rehabilitation CenterCCN 035174 · All quality measures
Overall star rating
4 of 5
Health inspections
3 of 5
Staffing
2 of 5
Quality measures
5 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Aug 3, 1988
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
200149.9 residents per day on average
Chain
The Ensign Group342 facilities in the chain
Penalties (3 years)
1Fines totaling $25,116

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory
Tax ID family
Esolutions Inc2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 8

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Elise T Vo Individual Operational/Managerial Control Mar 5, 2021
Adp of the SNF Mar 5, 2021
Ellen Cote Individual Operational/Managerial ControlAdministrator Nov 12, 2008
Adp of the SNF Nov 12, 2008
The Ensign Group Inc Organization, San Juan Capistrano, CA Corporation 5% Or Greater Indirect Ownership Interest Sep 1, 2003 100%
Ensign Services Inc Organization, San Juan Capistrano, CA Corporation Adp of the SNF Aug 1, 2003
Forrest Peterson Individual Corporate DirectorSole Manager Jan 1, 2019
Bandera Healthcare LLC Organization, San Juan Capistrano, CA Created for acquisition, LLC, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jan 30, 2006 100%
Chad Keetch Individual Corporate OfficerSecretary Ensign Services, Inc. Mar 1, 2011
Soon Burnam Individual Corporate OfficerSecretary Park Waverly Healthcare Oct 18, 2006

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 31

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 31

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1123545600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1613433600000",
    "number": "1629079975",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2001 NORTH PARK AVENUE",
            "city": "TUCSON",
            "state": "AZ",
            "postal_code": "857193558",
            "telephone_number": "520-882-6151",
            "fax_number": "520-620-1547"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2001 NORTH PARK AVENUE",
            "city": "TUCSON",
            "state": "AZ",
            "postal_code": "857193558",
            "telephone_number": "520-882-6151",
            "fax_number": "520-620-1547"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PARK WAVERLY HEALTHCARE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-09",
        "last_updated": "2021-02-16",
        "certification_date": "2021-02-16",
        "status": "A",
        "authorized_official_last_name": "BURNAM",
        "authorized_official_first_name": "SOON",
        "authorized_official_title_or_position": "AUTHORIZED AGENT",
        "authorized_official_telephone_number": "949-540-1249",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "AZ",
            "license": "NCI-2639",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113833.3.1066.1",
            "affiliationName": "eSolutions Inc.",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CSV",
            "address_1": "8215 W 108th Ter",
            "city": "Overland Park",
            "state": "KS",
            "country_code": "US",
            "postal_code": "662101661",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Park Avenue Health and Rehabilitaion Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Park Avenue Health and Rehabilitaion Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tucson, AZ

Sources for this page

Verify at the official NPI Registry.