Healthcare Provider Details

I. General information

NPI: 1396890620
Provider Name (Legal Business Name): THE WATKINS HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15372 W ROANOKE AVE
GOODYEAR AZ
85395-8980
US

IV. Provider business mailing address

15372 W ROANOKE AVE
GOODYEAR AZ
85395-8980
US

V. Phone/Fax

Practice location:
  • Phone: 623-535-5533
  • Fax: 623-535-6666
Mailing address:
  • Phone: 623-535-5533
  • Fax: 623-535-6666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberBH4267
License Number StateAZ

VIII. Authorized Official

Name: MRS. YVONNE ANN WATKINS
Title or Position: ADMINISTRATOR
Credential:
Phone: 623-535-5533