MEDICARE: TRINITY 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	320800000X	Mental Illness Community Based Residential Treatment Facility	BH-3897	AZ

General Provider Information

NPI Number	:	1861701146
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRINITY HOME LLC

Provider Business Mailing Address
First Line	:	2384 E CAMINO MALCOTE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85706-5191
Country	:	US
Telephone Number	:	520-207-5196
Fax Number	:	520-203-7567

Provider Business Practice Location Address
First Line	:	2384 E CAMINO MALCOTE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85706-5191
Country	:	US
Telephone Number	:	520-207-5196
Fax Number	:	520-203-7567

Authorized Official
Title or Position	:	ADMINISTRATOR/PROGRAM DIRECTOR
Name	:	MR. ROBERT NGONGHOPONGHO FORLEMU
Credential	:	MR.
Telephone Number	:	520-270-7061

Provider Enumeration Date	:	10/04/2010
Last Update Date	:	08/16/2011

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Directions to “TRINITY HOME LLC ” Practice Location

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