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General NPI Number Information
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NPI Number | 1538672076
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Entity Type | Organization
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Legal Business Name | MARTHA'S RESIDENTIAL CARE LLC
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Dates
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Enumeration Date | 11/07/2017
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Last Update Date | 11/07/2017
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Provider Practice Location Address
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Address Line | 14256 W FAIRMOUNT AVE
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City | GOODYEAR
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State | AZ
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Zip | 85395-8428
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Country | US
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Telephone | 480-217-6996
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Fax | 480-452-0243
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Provider Business Mailing Address
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Address Line | 22958 W PIMA ST
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City | BUCKEYE
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State | AZ
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Zip | 85326-8734
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Country | US
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Telephone | 623-271-8248
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Fax | 480-452-0243
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | SAFFIATU S TUNIS
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Credential |
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Telephone | 623-271-8248
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | BH5302
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License Number State | AZ
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