Healthcare Provider Details

I. General information

NPI: 1760233902
Provider Name (Legal Business Name): MAE'S PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13619 W BOCA RATON RD
SURPRISE AZ
85379
US

IV. Provider business mailing address

13794 W WADDELL RD # 203185
SURPRISE AZ
85379-8499
US

V. Phone/Fax

Practice location:
  • Phone: 480-913-4882
  • Fax:
Mailing address:
  • Phone: 148-091-3488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: LAKEYSHA DARBY
Title or Position: CEO
Credential:
Phone: 480-913-4882