=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093206427
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPRINGS OF JOY LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2018
-----------------------------------------------------
Last Update Date | 05/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 613 S 125TH AVE
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-8447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-228-7140
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 613 S 125TH AVE
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-8447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-228-7140
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MARTHA NYAWIRA GITOGO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-228-7140
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | BH5278
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------