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?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251S00000XAgenciesCommunity/Behavioral Health