Provider Demographics
NPI:1205357191
Name:KONADU FAMILY
Entity Type:Organization
Organization Name:KONADU FAMILY
Other - Org Name:KONADU FAMILY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:KONADU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-252-9164
Mailing Address - Street 1:40030 W COLTIN WAY
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138
Mailing Address - Country:US
Mailing Address - Phone:520-252-9164
Mailing Address - Fax:
Practice Address - Street 1:40030 W COLTIN WAY
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138
Practice Address - Country:US
Practice Address - Phone:520-252-9164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH5107Medicaid