Provider Demographics
NPI:1043634769
Name:EUREKA ANNEX RESIDENCE
Entity Type:Organization
Organization Name:EUREKA ANNEX RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:TANYI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-264-2647
Mailing Address - Street 1:1740 S HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-4851
Mailing Address - Country:US
Mailing Address - Phone:480-264-2647
Mailing Address - Fax:
Practice Address - Street 1:2668 S HERITAGE DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-7164
Practice Address - Country:US
Practice Address - Phone:480-264-2647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EUREKA IMPERIAL RESIDENCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-17
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility