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General NPI Number Information
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NPI Number | 1437532991
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Entity Type | Organization
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Legal Business Name | PRESIDENTIAL MANSIONCARE, LLC
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Dates
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Enumeration Date | 07/02/2015
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Last Update Date | 12/11/2023
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Provider Practice Location Address
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Address Line | 18428 W MIAMI ST
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City | GOODYEAR
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State | AZ
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Zip | 85338-7490
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Country | US
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Telephone | 623-202-9583
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Fax | 623-882-0715
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Provider Business Mailing Address
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Address Line | 1647 S 170TH AVE
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City | GOODYEAR
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State | AZ
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Zip | 85338-7324
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Country | US
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Telephone | 623-202-9583
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Fax | 623-215-2212
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | KENNEDY ABBA KEDAY AMUGHAN
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Credential | BHT
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Telephone | 623-202-9583
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | BH2753
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License Number State | AZ
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