1407482268 NPI number — LOLOMA HOUSES LLC

Table of content: (NPI 1407482268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407482268 NPI number — LOLOMA HOUSES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOLOMA HOUSES LLC
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:
6
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:
1407482268
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8408 W WILLOW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85381-4864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-418-6657
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6125 W SUNNYSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85304-2533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-418-6657
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/12/2020

Additional Information

Authorized Official

Authorized Official Last Name:
HORNBACK
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
ADILOBA
Authorized Official Title or Position:
OWNER / ADMINISTRATOR
Authorized Official Telephone Number:
623-418-6657

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1942743711 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com