Provider Demographics
NPI:1649972605
Name:605 S 30TH CIRCLE LLC
Entity type:Organization
Organization Name:605 S 30TH CIRCLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-760-5303
Mailing Address - Street 1:605 S 30TH CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-3119
Mailing Address - Country:US
Mailing Address - Phone:480-760-5303
Mailing Address - Fax:
Practice Address - Street 1:605 S 30TH CIR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-3119
Practice Address - Country:US
Practice Address - Phone:480-760-5303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMS LIVING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ85-3931252Medicaid