Provider Demographics
NPI:1558704809
Name:VALLEY INDEPENDENT RESIDENTIAL LLC
Entity Type:Organization
Organization Name:VALLEY INDEPENDENT RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWER
Authorized Official - Prefix:MR
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:SAAH
Authorized Official - Last Name:MCCABE
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:623-907-1142
Mailing Address - Street 1:6408 W GROSS AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-5778
Mailing Address - Country:US
Mailing Address - Phone:623-907-1142
Mailing Address - Fax:623-907-1143
Practice Address - Street 1:6408 W GROSS AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043
Practice Address - Country:US
Practice Address - Phone:623-907-1142
Practice Address - Fax:623-907-1143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4203320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness