Provider Demographics
NPI:1265050876
Name:ARIZONA ALTERNATIVE SUPPORT, LLC
Entity type:Organization
Organization Name:ARIZONA ALTERNATIVE SUPPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:N
Authorized Official - Last Name:MULONDO
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:774-253-7365
Mailing Address - Street 1:621 S WAYNE DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-2817
Mailing Address - Country:US
Mailing Address - Phone:774-253-7365
Mailing Address - Fax:
Practice Address - Street 1:36379 W EL GRECO ST
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-5323
Practice Address - Country:US
Practice Address - Phone:774-253-7365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities