Provider Demographics
NPI:1467198010
Name:DW DEVELOPMENTAL HOMES LLC
Entity Type:Organization
Organization Name:DW DEVELOPMENTAL HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SIMONA
Authorized Official - Middle Name:SHALLESE
Authorized Official - Last Name:WILFRED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-377-2710
Mailing Address - Street 1:9035 W GLOBE AVE
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-8642
Mailing Address - Country:US
Mailing Address - Phone:951-377-2710
Mailing Address - Fax:
Practice Address - Street 1:2609 NORTH 107TH AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85353
Practice Address - Country:US
Practice Address - Phone:951-377-2710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ00000000Medicaid