MEDICARE: EMMARIE BEHAVIORAL HOME CARE

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	BH-3103	AZ

General Provider Information

NPI Number	:	1578978409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMMARIE BEHAVIORAL HOME CARE

Provider Business Mailing Address
First Line	:	1638 E GREENWAY RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-5788
Country	:	US
Telephone Number	:	602-481-9789
Fax Number	:	602-268-1248

Provider Business Practice Location Address
First Line	:	2926 W WAYLAND DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-4436
Country	:	US
Telephone Number	:	602-276-2204
Fax Number	:	602-268-1248

Authorized Official
Title or Position	:	OWNER
Name	:	MR. EMMANUEL ADE EPIE
Credential	:
Telephone Number	:	602-481-9789

Provider Enumeration Date	:	06/30/2014
Last Update Date	:	06/30/2014

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