1578094827 NPI number — COMMUNITY SUPPORT SERVICES

Table of content: (NPI 1578094827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578094827 NPI number — COMMUNITY SUPPORT SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY SUPPORT SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578094827
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10645 N TATUM BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85028-3068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-309-4210
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
423 N COUNTRY CLUB DR
Provider Second Line Business Practice Location Address:
SUITE 36
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85201-5717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-309-4210
Provider Business Practice Location Address Fax Number:
480-629-5996
Provider Enumeration Date:
03/27/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ITAMI
Authorized Official First Name:
ARLETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
602-309-4210

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  CSLG7618 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)