Healthcare Provider Details

I. General information

NPI: 1841137064
Provider Name (Legal Business Name): CHAMBLISS FAMILY & YOUTH GROUP HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22611 W YAVAPAI ST
BUCKEYE AZ
85326-8953
US

IV. Provider business mailing address

22611 W YAVAPAI ST
BUCKEYE AZ
85326-8953
US

V. Phone/Fax

Practice location:
  • Phone: 662-617-9143
  • Fax:
Mailing address:
  • Phone: 662-617-9143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: TREVONTE CHAMBLISS
Title or Position: ADMIN
Credential:
Phone: 662-617-9143