MEDICARE: MARTHA'S RESIDENTIAL CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1841826260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARTHA'S RESIDENTIAL CARE LLC

Provider Business Mailing Address
First Line	:	7008 W CARTER RD
Second Line	:
City	:	LAVEEN
State	:	AZ
Zip	:	85339-7055
Country	:	US
Telephone Number	:	602-675-4326
Fax Number	:

Provider Business Practice Location Address
First Line	:	7008 W CARTER RD
Second Line	:
City	:	LAVEEN
State	:	AZ
Zip	:	85339-7055
Country	:	US
Telephone Number	:	602-675-4326
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	SAFFIATU S TUNIS
Credential	:
Telephone Number	:	623-271-8248

Provider Enumeration Date	:	03/17/2020
Last Update Date	:	03/17/2020

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