Provider Demographics
NPI:1477060341
Name:PARK GROVE LLC
Entity Type:Organization
Organization Name:PARK GROVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REEM
Authorized Official - Middle Name:
Authorized Official - Last Name:NAEUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-565-0010
Mailing Address - Street 1:348 S PARK GROVE LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1731
Mailing Address - Country:US
Mailing Address - Phone:623-565-0010
Mailing Address - Fax:
Practice Address - Street 1:348 S PARK GROVE LN
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-1731
Practice Address - Country:US
Practice Address - Phone:623-565-0010
Practice Address - Fax:623-565-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities