MEDICARE: MARY GROUP HOME 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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1760342083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY GROUP HOME LLC

Provider Business Mailing Address
First Line	:	12643 N 22ND AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-2652
Country	:	US
Telephone Number	:	480-577-7777
Fax Number	:

Provider Business Practice Location Address
First Line	:	12643 N 22ND AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-2652
Country	:	US
Telephone Number	:	480-577-7777
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ABDALLA ELKHALIFA
Credential	:
Telephone Number	:	480-577-7777

Provider Enumeration Date	:	11/18/2025
Last Update Date	:	11/18/2025

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