Healthcare Provider Details

I. General information

NPI: 1376320374
Provider Name (Legal Business Name): MARYS GROUP HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2023
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10008 W BLOCH RD
TOLLESON AZ
85353-4446
US

IV. Provider business mailing address

10008 W BLOCH RD
TOLLESON AZ
85353-4446
US

V. Phone/Fax

Practice location:
  • Phone: 602-621-2931
  • Fax: 623-398-8666
Mailing address:
  • Phone: 602-621-2931
  • Fax: 623-398-8666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MAIRELIS ZALDIVAR-SALAZAR
Title or Position: OWNER
Credential:
Phone: 602-621-2931