Healthcare Provider Details

I. General information

NPI: 1043634769
Provider Name (Legal Business Name): EUREKA ANNEX RESIDENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2014
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2668 S HERITAGE DR
GILBERT AZ
85295-7164
US

IV. Provider business mailing address

1740 S HERITAGE DR
GILBERT AZ
85295-4851
US

V. Phone/Fax

Practice location:
  • Phone: 480-264-2647
  • Fax:
Mailing address:
  • Phone: 480-264-2647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. CORNELIUS TANYI
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 480-264-2647