Healthcare Provider Details

I. General information

NPI: 1497808851
Provider Name (Legal Business Name): BIG JOHN GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12406 W SURREY AVE
EL MIRAGE AZ
85335-7245
US

IV. Provider business mailing address

70 S VAL VISTA DR STE A3 # 488
GILBERT AZ
85296-1375
US

V. Phone/Fax

Practice location:
  • Phone: 480-202-2972
  • Fax: 623-546-0161
Mailing address:
  • Phone: 480-202-2972
  • Fax: 623-546-0161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number864828
License Number StateAZ

VIII. Authorized Official

Name: STEPHANIE KAY EDWARDS
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 480-202-2972