MEDICARE: MR. DARRELL LEMONT ELLIS JR. ADMINISTRATOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	BHRF20103	AZ

General Provider Information

NPI Number	:	1174925424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DARRELL LEMONT ELLIS JR. ADMINISTRATOR

Provider Business Mailing Address
First Line	:	43646 W YUCCA LN
Second Line	:
City	:	MARICOPA
State	:	AZ
Zip	:	85138-2011
Country	:	US
Telephone Number	:	520-483-4219
Fax Number	:

Provider Business Practice Location Address
First Line	:	43646 W YUCCA LN
Second Line	:
City	:	MARICOPA
State	:	AZ
Zip	:	85138-2011
Country	:	US
Telephone Number	:	520-483-4219
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2014
Last Update Date	:	12/06/2025

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