Provider Demographics
NPI:1255061032
Name:MON AMI 2 GROUP HOME LLC
Entity type:Organization
Organization Name:MON AMI 2 GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
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:BHT
Authorized Official - Phone:602-677-6359
Mailing Address - Street 1:40975 W MARY LOU DR
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-5433
Mailing Address - Country:US
Mailing Address - Phone:602-677-6359
Mailing Address - Fax:480-530-5408
Practice Address - Street 1:40975 W MARY LOU DR
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-5433
Practice Address - Country:US
Practice Address - Phone:602-677-6359
Practice Address - Fax:480-530-5408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children