Provider Demographics
NPI:1548785884
Name:AZ COMFORT HOME LLC
Entity Type:Organization
Organization Name:AZ COMFORT HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:OMIJIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-326-3327
Mailing Address - Street 1:23832 W TONTO ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-8139
Mailing Address - Country:US
Mailing Address - Phone:623-666-3895
Mailing Address - Fax:623-321-1206
Practice Address - Street 1:23832 W TONTO STREET
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326
Practice Address - Country:US
Practice Address - Phone:623-666-3895
Practice Address - Fax:623-321-1206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5219320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities