=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154061398
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESTIGE RESIDENTIAL HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2022
-----------------------------------------------------
Last Update Date | 03/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22367 E DESERT SPOON DR
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85142-1235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-307-9984
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22367 E DESERT SPOON DR
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85142-1235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-307-9984
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | ALEXANDER B ASIEDU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 914-417-0214
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------