MEDICARE: FG RESIDENTIAL HOMES LLC

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	3104A0630X	Assisted Living Facility (Behavioral Disturbances)

General Provider Information

NPI Number	:	1184408619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FG RESIDENTIAL HOMES LLC

Provider Business Mailing Address
First Line	:	8414 N 31ST LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-6006
Country	:	US
Telephone Number	:	602-418-2494
Fax Number	:

Provider Business Practice Location Address
First Line	:	7316 W CORDES RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85043-7260
Country	:	US
Telephone Number	:	602-418-2494
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	FRANK GYAMFI
Credential	:
Telephone Number	:	602-418-2494

Provider Enumeration Date	:	08/24/2023
Last Update Date	:	08/24/2023

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