Healthcare Provider Details

I. General information

NPI: 1316694417
Provider Name (Legal Business Name): OHANA DEVELOPMENTAL HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2022
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 W SOUTHERN AVE STE 106
PHOENIX AZ
85041-4501
US

IV. Provider business mailing address

2710 W SOUTHERN AVE STE 106
PHOENIX AZ
85041-4501
US

V. Phone/Fax

Practice location:
  • Phone: 602-341-6990
  • Fax:
Mailing address:
  • Phone: 602-341-6990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MARK ABRAM
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 623-680-6843