Provider Demographics
NPI:1437518537
Name:GOMPERS HABILITATION CENTER
Entity Type:Organization
Organization Name:GOMPERS HABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN SCHOOL NURSE
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-227-8660
Mailing Address - Street 1:6601 N 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-1219
Mailing Address - Country:US
Mailing Address - Phone:602-336-0061
Mailing Address - Fax:602-336-0249
Practice Address - Street 1:6601 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-1219
Practice Address - Country:US
Practice Address - Phone:602-336-0061
Practice Address - Fax:602-336-0249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP030525313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility