1578736039 NPI number — TRI-PHASE GROUP HOME INC

Table of content: (NPI 1578736039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578736039 NPI number — TRI-PHASE GROUP HOME INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-PHASE GROUP HOME INC
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:
1578736039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18403 W VERDIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOODYEAR
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85338-5081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-474-6326
Provider Business Mailing Address Fax Number:
623-474-6516

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 S LAZONA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85204-1222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-474-6326
Provider Business Practice Location Address Fax Number:
623-474-6516
Provider Enumeration Date:
04/04/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCKINNEY
Authorized Official First Name:
SHERRI
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DIRECTOR
Authorized Official Telephone Number:
623-474-6326

Provider Taxonomy Codes

  • Taxonomy code: 3245S0500X , with the licence number:  BH-3081 , 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)