Healthcare Provider Details

I. General information

NPI: 1588998520
Provider Name (Legal Business Name): P.O.W.E.R. HOUSE YOUTH FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3039 E SUPERIOR RD
QUEEN CREEK AZ
85143-4580
US

IV. Provider business mailing address

PO BOX 51660
MESA AZ
85208-0083
US

V. Phone/Fax

Practice location:
  • Phone: 480-458-5171
  • Fax: 480-268-7167
Mailing address:
  • Phone: 480-268-1766
  • Fax: 480-268-7167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateAZ

VIII. Authorized Official

Name: MR. GLEN ALLEN MAYBERRY
Title or Position: C.E.O.
Credential: M.A. ED
Phone: 480-203-3519