Provider Demographics
NPI:1407482268
Name:LOLOMA HOUSES LLC
Entity Type:Organization
Organization Name:LOLOMA HOUSES LLC
Other - Org Name:LOLOMA HOUSE AT GREENWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:ADILOBA
Authorized Official - Last Name:HORNBACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-418-6657
Mailing Address - Street 1:8408 W WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4864
Mailing Address - Country:US
Mailing Address - Phone:623-418-6657
Mailing Address - Fax:
Practice Address - Street 1:6125 W SUNNYSIDE DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-2533
Practice Address - Country:US
Practice Address - Phone:623-418-6657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOLOMA HOUSE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-12
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1942743711Medicaid