Provider Demographics
NPI:1437532991
Name:PRESIDENTIAL MANSIONCARE, LLC
Entity Type:Organization
Organization Name:PRESIDENTIAL MANSIONCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNEDY
Authorized Official - Middle Name:ABBA KEDAY
Authorized Official - Last Name:AMUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:BHT
Authorized Official - Phone:623-202-9583
Mailing Address - Street 1:1647 S 170TH AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-7324
Mailing Address - Country:US
Mailing Address - Phone:623-202-9583
Mailing Address - Fax:623-215-2212
Practice Address - Street 1:18428 W MIAMI ST
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-7490
Practice Address - Country:US
Practice Address - Phone:623-202-9583
Practice Address - Fax:623-882-0715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH2753320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities