Healthcare Provider Details

I. General information

NPI: 1649907148
Provider Name (Legal Business Name): RESIDENTIAL GROUPHOME SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6102 S 37TH LN
PHOENIX AZ
85041-5021
US

IV. Provider business mailing address

1805 E ALTA VISTA RD
PHOENIX AZ
85042-4551
US

V. Phone/Fax

Practice location:
  • Phone: 602-718-8809
  • Fax:
Mailing address:
  • Phone: 602-718-8809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ROBERT MCNEAL
Title or Position: OWNER /OPERATOR
Credential: BS
Phone: 602-718-8809