Provider Demographics
NPI:1265036230
Name:MOMENTOUS ADULT FOSTER CARE
Entity Type:Organization
Organization Name:MOMENTOUS ADULT FOSTER CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER OF ASSISTED
Authorized Official - Phone:520-222-2335
Mailing Address - Street 1:6102 E TIMROD ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-4664
Mailing Address - Country:US
Mailing Address - Phone:520-222-2335
Mailing Address - Fax:
Practice Address - Street 1:6102 E TIMROD ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-4664
Practice Address - Country:US
Practice Address - Phone:520-222-2335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home