1467198010 NPI number — DW DEVELOPMENTAL HOMES LLC

Table of content: MRS. SUSAN ROBERTA CAIN OPTICIAN (NPI 1700089349)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467198010 NPI number — DW DEVELOPMENTAL HOMES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DW DEVELOPMENTAL HOMES 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:
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:
1467198010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9035 W GLOBE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLLESON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85353-8642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-377-2710
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2609 NORTH 107TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AVONDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-377-2710
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2022

Additional Information

Authorized Official

Authorized Official Last Name:
WILFRED
Authorized Official First Name:
SIMONA
Authorized Official Middle Name:
SHALLESE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
951-377-2710

Provider Taxonomy Codes

  • Taxonomy code: 320600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00000000 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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