Provider Demographics
NPI:1740974336
Name:A GREATER VISION LIVING SPACE LLC.
Entity type:Organization
Organization Name:A GREATER VISION LIVING SPACE LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-203-5920
Mailing Address - Street 1:7252 W QUAIL TRACK DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-6362
Mailing Address - Country:US
Mailing Address - Phone:623-203-5920
Mailing Address - Fax:
Practice Address - Street 1:7252 W QUAIL TRACK DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-6362
Practice Address - Country:US
Practice Address - Phone:623-203-5920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-06
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health