Healthcare Provider Details

I. General information

NPI: 1942424361
Provider Name (Legal Business Name): BLUE MOUNTAIN DEVELOPMENTAL PROGRAMS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 09/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13939 W GRAND AVE
SURPRISE AZ
85374-2440
US

IV. Provider business mailing address

13954 W WADDELL RD STE 103
SURPRISE AZ
85379-8751
US

V. Phone/Fax

Practice location:
  • Phone: 623-584-5990
  • Fax:
Mailing address:
  • Phone: 623-584-5990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MS. GENEVA MELANIE WARD
Title or Position: DIRECTOR
Credential: M.ED.
Phone: 623-584-5990