Healthcare Provider Details

I. General information

NPI: 1013481993
Provider Name (Legal Business Name): MON AMI GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9138 E DENNIS ST
MESA AZ
85207-6008
US

IV. Provider business mailing address

9138 E DENNIS ST
MESA AZ
85207-6008
US

V. Phone/Fax

Practice location:
  • Phone: 480-380-4413
  • Fax:
Mailing address:
  • Phone: 480-380-4413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. SALIM OTIENO ODIERO
Title or Position: ADMINISTRATOR
Credential: CEO
Phone: 503-805-9203