Provider Demographics
NPI:1720579022
Name:MILLENNIUM RESIDENTIAL HOME INC.
Entity Type:Organization
Organization Name:MILLENNIUM RESIDENTIAL HOME INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMIADI
Authorized Official - Middle Name:
Authorized Official - Last Name:EDOGI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-418-2266
Mailing Address - Street 1:10325 W SAN JUAN AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85307-4310
Mailing Address - Country:US
Mailing Address - Phone:623-418-2266
Mailing Address - Fax:623-218-1520
Practice Address - Street 1:10325 W SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85307-4310
Practice Address - Country:US
Practice Address - Phone:623-418-2266
Practice Address - Fax:623-218-1520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances