1194888073 NPI number — FREEDOM MANOR, INC.

Table of content: (NPI 1194888073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194888073 NPI number — FREEDOM MANOR, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FREEDOM MANOR, 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:
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:
1194888073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2524 E HEATHERBRAE DR
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:
85016-5668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-956-5556
Provider Business Mailing Address Fax Number:
602-957-6556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
628 E KNOLL ST
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:
85203-1807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-956-5556
Provider Business Practice Location Address Fax Number:
602-957-6556
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
602-956-5556

Provider Taxonomy Codes

  • Taxonomy code: 177F00000X , with the licence number:  ALH-4155 , 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)

  • Identifier: 755126 . This is a "PROVIDER ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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