Healthcare Provider Details

I. General information

NPI: 1376478917
Provider Name (Legal Business Name): MARIN HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35918 W MARIN AVE
MARICOPA AZ
85138-2533
US

IV. Provider business mailing address

35918 W MARIN AVE
MARICOPA AZ
85138-2533
US

V. Phone/Fax

Practice location:
  • Phone: 520-350-1219
  • Fax:
Mailing address:
  • Phone: 520-350-1219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS LANE
Title or Position: HOUSE MANAGER
Credential: MBA
Phone: 602-628-4127