Healthcare Provider Details

I. General information

NPI: 1528722790
Provider Name (Legal Business Name): PROGRESSIVE LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 E GLASS LN
PHOENIX AZ
85042-5819
US

IV. Provider business mailing address

1314 E GLASS LN
PHOENIX AZ
85042-5819
US

V. Phone/Fax

Practice location:
  • Phone: 480-773-8480
  • Fax: 480-546-3626
Mailing address:
  • Phone: 480-773-8480
  • Fax: 480-546-3626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: LYDDIA GETAWERU
Title or Position: CEO/OWNER
Credential: MBA
Phone: 480-773-8480