Healthcare Provider Details

I. General information

NPI: 1396914735
Provider Name (Legal Business Name): TRI-PHASE GROUP HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 E BETSY LN UNIT D
GILBERT AZ
85296-3759
US

IV. Provider business mailing address

18403 W VERDIN RD
GOODYEAR AZ
85338-5081
US

V. Phone/Fax

Practice location:
  • Phone: 623-474-6326
  • Fax: 623-474-6516
Mailing address:
  • Phone: 623-474-6326
  • Fax: 623-474-6516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License NumberBH-1914
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberBH-1914
License Number StateAZ

VIII. Authorized Official

Name: MRS. SHERRI MCKINNEY
Title or Position: DIRECTOR
Credential:
Phone: 623-474-6326