Provider Demographics
NPI:1952717654
Name:TOLLESON HEALTH CARE
Entity type:Organization
Organization Name:TOLLESON HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:IFFA
Authorized Official - Middle Name:DIRIBA
Authorized Official - Last Name:WOLKABA
Authorized Official - Suffix:
Authorized Official - Credentials:SOCIAL WORKER
Authorized Official - Phone:602-330-2203
Mailing Address - Street 1:10314 W SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-8423
Mailing Address - Country:US
Mailing Address - Phone:602-330-2203
Mailing Address - Fax:623-792-7488
Practice Address - Street 1:10314 W SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-8423
Practice Address - Country:US
Practice Address - Phone:602-330-2203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL9017H320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD00778622OtherSOCIAL WORK