Provider Demographics
NPI:1861024069
Name:NEW ROOTS RESIDENCY LLC
Entity Type:Organization
Organization Name:NEW ROOTS RESIDENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:WANJA
Authorized Official - Last Name:MUTHONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-285-5483
Mailing Address - Street 1:3139 W CARSON RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-6342
Mailing Address - Country:US
Mailing Address - Phone:480-285-5483
Mailing Address - Fax:602-675-1560
Practice Address - Street 1:3139 W CARSON RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-6342
Practice Address - Country:US
Practice Address - Phone:480-285-5483
Practice Address - Fax:602-675-1560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities