Provider Demographics
NPI:1629528716
Name:EXCLUSIVE CERTIFIED RESIDENTIAL CARE, LLC
Entity Type:Organization
Organization Name:EXCLUSIVE CERTIFIED RESIDENTIAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROYCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-285-9595
Mailing Address - Street 1:33105 N 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-5088
Mailing Address - Country:US
Mailing Address - Phone:623-285-9595
Mailing Address - Fax:928-255-1741
Practice Address - Street 1:3744 MARTINGALE DR
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-2994
Practice Address - Country:US
Practice Address - Phone:928-255-1747
Practice Address - Fax:928-255-1741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4985320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness