Provider Demographics
NPI: | 1013481993 |
---|---|
Name: | MON AMI GROUP HOME |
Entity Type: | Organization |
Organization Name: | MON AMI GROUP HOME |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | ADMINISTRATOR |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | SALIM |
Authorized Official - Middle Name: | OTIENO |
Authorized Official - Last Name: | ODIERO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | CEO |
Authorized Official - Phone: | 503-805-9203 |
Mailing Address - Street 1: | 9138 E DENNIS ST |
Mailing Address - Street 2: | |
Mailing Address - City: | MESA |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85207-6008 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 480-380-4413 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 9138 E DENNIS ST |
Practice Address - Street 2: | |
Practice Address - City: | MESA |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85207-6008 |
Practice Address - Country: | US |
Practice Address - Phone: | 480-380-4413 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-01-14 |
Last Update Date: | 2020-06-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 320900000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
No | 251S00000X | Agencies | Community/Behavioral Health |