Healthcare Provider Details

I. General information

NPI: 1063519155
Provider Name (Legal Business Name): MENLO HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 W PLACITA PLATA
TUCSON AZ
85745-2722
US

IV. Provider business mailing address

1323 W PLACITA PLATA
TUCSON AZ
85745-2722
US

V. Phone/Fax

Practice location:
  • Phone: 520-628-8251
  • Fax: 520-207-6369
Mailing address:
  • Phone: 520-628-8251
  • Fax: 520-207-6369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberBH2111
License Number StateAZ

VIII. Authorized Official

Name: MS. ELIZABETH MARY FORD
Title or Position: ADMINISTRATOR
Credential:
Phone: 520-628-8251