Provider Demographics
NPI:1255484366
Name:BIG JOHN GROUP HOME
Entity Type:Organization
Organization Name:BIG JOHN GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-202-2972
Mailing Address - Street 1:70 S VAL VISTA DR STE A3 # 44
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1375
Mailing Address - Country:US
Mailing Address - Phone:480-202-2972
Mailing Address - Fax:623-546-0161
Practice Address - Street 1:12514 N 126TH LN
Practice Address - Street 2:
Practice Address - City:EL MIRAGE
Practice Address - State:AZ
Practice Address - Zip Code:85335-5206
Practice Address - Country:US
Practice Address - Phone:480-202-2972
Practice Address - Fax:623-546-0161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ723636322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children