Provider Demographics
NPI:1225621485
Name:SUCCESS RESIDENCE LLC
Entity Type:Organization
Organization Name:SUCCESS RESIDENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MAAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABUKARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-891-4320
Mailing Address - Street 1:5120 E WALLACE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5161
Mailing Address - Country:US
Mailing Address - Phone:917-891-4320
Mailing Address - Fax:
Practice Address - Street 1:5120 E WALLACE WAY
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-5161
Practice Address - Country:US
Practice Address - Phone:917-891-4320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty