1588998520 NPI number — P.O.W.E.R. HOUSE YOUTH FACILITY

Table of content: (NPI 1588998520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588998520 NPI number — P.O.W.E.R. HOUSE YOUTH FACILITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
P.O.W.E.R. HOUSE YOUTH FACILITY
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:
1588998520
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51660
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:
85208-0083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-268-1766
Provider Business Mailing Address Fax Number:
480-268-7167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3039 E SUPERIOR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUEEN CREEK
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85143-4580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-458-5171
Provider Business Practice Location Address Fax Number:
480-268-7167
Provider Enumeration Date:
09/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MAYBERRY
Authorized Official First Name:
GLEN
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
480-203-3519

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , 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)





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