Provider Demographics
NPI:1508591561
Name:GOOD SAMARITAN RESIDENTIAL CARE LLC
Entity Type:Organization
Organization Name:GOOD SAMARITAN RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIDIER
Authorized Official - Middle Name:
Authorized Official - Last Name:TWAGIRAYEZU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-480-3474
Mailing Address - Street 1:1536 E INOUYE DR
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-6590
Mailing Address - Country:US
Mailing Address - Phone:817-480-3474
Mailing Address - Fax:
Practice Address - Street 1:1536 E INOUYE DR
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-6590
Practice Address - Country:US
Practice Address - Phone:817-480-3474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH7786OtherAZDHS