Provider Demographics
NPI:1831625532
Name:GARDENIA TRANQUILITY
Entity type:Organization
Organization Name:GARDENIA TRANQUILITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALINF SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DELPHINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-888-2123
Mailing Address - Street 1:4929 E LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-4640
Mailing Address - Country:US
Mailing Address - Phone:480-888-2123
Mailing Address - Fax:
Practice Address - Street 1:4929 E LAUREL LN
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4640
Practice Address - Country:US
Practice Address - Phone:480-888-2123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH3855323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ231735Medicaid