Provider Demographics
NPI:1538672076
Name:MARTHA'S RESIDENTIAL CARE LLC
Entity Type:Organization
Organization Name:MARTHA'S RESIDENTIAL CARE LLC
Other - Org Name:MARTHA'S RESIDENTIAL CARE LLC - FAIRMOUNT HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAFFIATU
Authorized Official - Middle Name:S
Authorized Official - Last Name:TUNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-271-8248
Mailing Address - Street 1:22958 W PIMA ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-8734
Mailing Address - Country:US
Mailing Address - Phone:623-271-8248
Mailing Address - Fax:480-452-0243
Practice Address - Street 1:14256 W FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-8428
Practice Address - Country:US
Practice Address - Phone:480-217-6996
Practice Address - Fax:480-452-0243
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARTHA'S RESIDENTIAL CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5302320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness