Provider Demographics
NPI:1649907148
Name:RESIDENTIAL GROUPHOME SERVICES LLC
Entity type:Organization
Organization Name:RESIDENTIAL GROUPHOME SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER /OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNEAL
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:602-718-8809
Mailing Address - Street 1:1805 E ALTA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-4551
Mailing Address - Country:US
Mailing Address - Phone:602-718-8809
Mailing Address - Fax:
Practice Address - Street 1:6102 S 37TH LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-5021
Practice Address - Country:US
Practice Address - Phone:602-718-8809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-04
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251E00000XAgenciesHome Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ103TC0700XMedicaid
AZ103TA0400XMedicaid
AZ103TC1900XMedicaid
AZ103TP2701XMedicaid