MEDICARE: INFINITY GROUPS 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	261QM0850X	Adult Mental Health Clinic/Center	BH4839	AZ

General Provider Information

NPI Number	:	1770931008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INFINITY GROUPS HOMES LLC

Provider Business Mailing Address
First Line	:	15111 N 33RD PL
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-4552
Country	:	US
Telephone Number	:	480-907-4474
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	:	480-907-4474
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MOZAMIL GABIR ABDELRAHMAN
Credential	:
Telephone Number	:	480-907-4474

Provider Enumeration Date	:	05/26/2016
Last Update Date	:	05/26/2016

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