MEDICARE: MATTIE'S CARE HOUSE, 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	320800000X	Mental Illness Community Based Residential Treatment Facility	BH4867	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	148847	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1447601448
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATTIE'S CARE HOUSE, LLC

Provider Business Mailing Address
First Line	:	6823 W PLEASANT LN
Second Line	:
City	:	LAVEEN
State	:	AZ
Zip	:	85339-2660
Country	:	US
Telephone Number	:	602-686-0419
Fax Number	:	602-687-9742

Provider Business Practice Location Address
First Line	:	6823 W PLEASANT LN
Second Line	:
City	:	LAVEEN
State	:	AZ
Zip	:	85339-2660
Country	:	US
Telephone Number	:	602-686-0419
Fax Number	:	602-687-9742

Authorized Official
Title or Position	:	CEO/ADMINISTRATOR
Name	:	LATOYA J. LEE
Credential	:
Telephone Number	:	602-686-0419

Provider Enumeration Date	:	06/30/2016
Last Update Date	:	07/14/2016

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