Provider Demographics
NPI:1447795992
Name:MISS A'S LLC
Entity Type:Organization
Organization Name:MISS A'S LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALLISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DENEKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-670-0039
Mailing Address - Street 1:5421 W DESERT HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-2703
Mailing Address - Country:US
Mailing Address - Phone:623-670-0039
Mailing Address - Fax:623-234-2475
Practice Address - Street 1:8606 N 68TH LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-8451
Practice Address - Country:US
Practice Address - Phone:623-234-2475
Practice Address - Fax:623-234-2475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5029320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ222757Medicaid