Provider Demographics
NPI:1194050278
Name:OZAREE PLACE 1
Entity type:Organization
Organization Name:OZAREE PLACE 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:ORLANDER
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-469-0802
Mailing Address - Street 1:7409 S 26TH LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-6477
Mailing Address - Country:US
Mailing Address - Phone:602-237-5584
Mailing Address - Fax:602-323-5021
Practice Address - Street 1:7409 S 26TH LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-6477
Practice Address - Country:US
Practice Address - Phone:602-237-5584
Practice Address - Fax:602-323-5021
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLO ENTERPRISES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-07
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH3418101Y00000X, 322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed ChildrenGroup - Multi-Specialty