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General NPI Number Information
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NPI Number | 1588524110
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Entity Type | Organization
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Legal Business Name | SUCCESS BEHAVIORAL GROUP HOME LLC 1
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Dates
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Enumeration Date | 11/15/2025
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Last Update Date | 11/15/2025
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Provider Practice Location Address
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Address Line | 9557 W AGORA LN
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City | TOLLESON
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State | AZ
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Zip | 85353-4565
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Country | US
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Telephone | 602-558-5847
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Fax | 602-671-6752
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Provider Business Mailing Address
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Address Line | 9557 W AGORA LN
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City | TOLLESON
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State | AZ
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Zip | 85353-4565
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Country | US
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Telephone | 602-558-5847
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Fax | 602-671-6752
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | EWOMAZINO JOY OMASERE
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Credential |
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Telephone | 903-917-8122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320700000X
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Taxonomy Name | Physical Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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