Provider Demographics
NPI:1639740723
Name:TRINITY RECOVERY HOME LLC
Entity Type:Organization
Organization Name:TRINITY RECOVERY HOME LLC
Other - Org Name:GUEST HOUSE RECOVERY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SURROGATE
Authorized Official - Prefix:
Authorized Official - First Name:SYDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-837-6800
Mailing Address - Street 1:4374 N 153RD DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-8392
Mailing Address - Country:US
Mailing Address - Phone:623-295-2323
Mailing Address - Fax:
Practice Address - Street 1:4374 N 153RD DR
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-8392
Practice Address - Country:US
Practice Address - Phone:623-295-2323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRINITY RECOVERY HOME LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-08
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ85-1549738Medicaid