Provider Demographics
NPI:1215588629
Name:MON AMI GROUP HOME
Entity Type:Organization
Organization Name:MON AMI GROUP HOME
Other - Org Name:MONAMI GROUP HOME LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:MR
Authorized Official - First Name:SALIM
Authorized Official - Middle Name:OTIENO
Authorized Official - Last Name:ODIERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-380-4413
Mailing Address - Street 1:9138 E DENNIS ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-6008
Mailing Address - Country:US
Mailing Address - Phone:480-380-4413
Mailing Address - Fax:480-530-5408
Practice Address - Street 1:9138 E DENNIS ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-6008
Practice Address - Country:US
Practice Address - Phone:480-380-4413
Practice Address - Fax:480-530-5408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-26
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty