1578508883 NPI number — SURVIVORS EDUCATING LOVING FRIENDS AND FAMILY, INC.

Table of content: (NPI 1578508883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578508883 NPI number — SURVIVORS EDUCATING LOVING FRIENDS AND FAMILY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURVIVORS EDUCATING LOVING FRIENDS AND FAMILY, 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:
SELFF, INC.
Provider Other Organization Name Type Code:
3
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:
1578508883
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:
340 W UNIVERSITY DR STE 19
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85201-5827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-649-3642
Provider Business Mailing Address Fax Number:
480-668-8919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 W UNIVERSITY DR STE 19
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:
85201-5827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-649-3642
Provider Business Practice Location Address Fax Number:
480-668-8919
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLETH
Authorized Official First Name:
TRISH
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
480-649-3642

Provider Taxonomy Codes

  • Taxonomy code: 251V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CSA03VO0100 . This is a "COVERED SERVICE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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