Provider Demographics
NPI:1043277569
Name:GOMPER'S CENTER, INC.
Entity Type:Organization
Organization Name:GOMPER'S CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-336-0061
Mailing Address - Street 1:6601 N 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-1219
Mailing Address - Country:US
Mailing Address - Phone:602-336-0061
Mailing Address - Fax:602-336-0249
Practice Address - Street 1:6601 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-1219
Practice Address - Country:US
Practice Address - Phone:602-336-0061
Practice Address - Fax:602-336-0249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAHCCCS ID 811720251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services