Provider Demographics
NPI:1245944511
Name:LIDA REDIRECT ASSIST LLC
Entity type:Organization
Organization Name:LIDA REDIRECT ASSIST LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BRAND OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-627-0187
Mailing Address - Street 1:2550 W UNION HILLS DR STE 350
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-5187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2550 W UNION HILLS DR STE 350
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-5187
Practice Address - Country:US
Practice Address - Phone:760-627-0187
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-10
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No253Z00000XAgenciesIn Home Supportive Care
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities