Provider Demographics
NPI:1467666131
Name:FAY'S HOUSE 1,2,3 LLC
Entity Type:Organization
Organization Name:FAY'S HOUSE 1,2,3 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEE'ANNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MCQUILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-304-0316
Mailing Address - Street 1:408 W BEVERLY RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-8111
Mailing Address - Country:US
Mailing Address - Phone:602-304-0316
Mailing Address - Fax:602-276-0138
Practice Address - Street 1:408 W BEVERLY RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-8111
Practice Address - Country:US
Practice Address - Phone:602-304-0316
Practice Address - Fax:602-276-0138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH 2693322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ146283Medicaid