Healthcare Provider Details

I. General information

NPI: 1467500488
Provider Name (Legal Business Name): FRIENDSHIP HOUSE-RVCCC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 E THIRD AVE
EAGAR AZ
85925
US

IV. Provider business mailing address

PO BOX 578
EAGAR AZ
85925-0578
US

V. Phone/Fax

Practice location:
  • Phone: 928-333-5975
  • Fax:
Mailing address:
  • Phone: 928-333-5975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateAZ

VIII. Authorized Official

Name: DARLENE J PULSIPHER
Title or Position: OWNER
Credential:
Phone: 928-333-5975