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General NPI Number Information
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NPI Number | 1053702563
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Entity Type | Organization
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Legal Business Name | HOME AWAY FROM HOME BEHAVIORAL HEALTH RESIDENTIAL FACILITY
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Dates
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Enumeration Date | 02/05/2015
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Last Update Date | 02/05/2015
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Provider Practice Location Address
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Address Line | 8572 W PALO VERDE AVE
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City | PEORIA
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State | AZ
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Zip | 85345-5354
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Country | US
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Telephone | 623-312-3485
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Fax |
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Provider Business Mailing Address
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Address Line | 8572 W PALO VERDE AVE
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City | PEORIA
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State | AZ
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Zip | 85345-5354
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Country | US
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Telephone | 623-312-3485
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. TANYA M AYIYI
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Credential |
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Telephone | 623-312-3485
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | BH4513
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License Number State | AZ
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