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General NPI Number Information
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NPI Number | 1255061032
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Entity Type | Organization
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Legal Business Name | MON AMI 2 GROUP HOME LLC
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Dates
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Enumeration Date | 06/14/2022
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Last Update Date | 06/14/2022
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Provider Practice Location Address
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Address Line | 40975 W MARY LOU DR
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City | MARICOPA
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State | AZ
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Zip | 85138-5433
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Country | US
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Telephone | 602-677-6359
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Fax | 480-530-5408
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Provider Business Mailing Address
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Address Line | 40975 W MARY LOU DR
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City | MARICOPA
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State | AZ
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Zip | 85138-5433
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Country | US
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Telephone | 602-677-6359
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Fax | 480-530-5408
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Authorized Official
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Title or Position | CEO
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Name | MR. SALIM OTIENO ODIERO
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Credential | BHT
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Telephone | 602-677-6359
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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 |
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License Number State |
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