Provider Demographics
NPI:1962818187
Name:MARTHA'S RESIDENTIAL CARE LLC
Entity Type:Organization
Organization Name:MARTHA'S RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAFFIATU
Authorized Official - Middle Name:S
Authorized Official - Last Name:TUNIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:480-217-6996
Mailing Address - Street 1:22958 W PIMA ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-8734
Mailing Address - Country:US
Mailing Address - Phone:623-271-8248
Mailing Address - Fax:480-452-0243
Practice Address - Street 1:8572 W PALO VERDE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-5354
Practice Address - Country:US
Practice Address - Phone:480-217-6996
Practice Address - Fax:480-452-0243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4469320800000X
AZBH4907320800000X
320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH6971OtherLICENSE