Provider Demographics
NPI:1306585666
Name:TSAFACK RESIDENTIAL CARE LLC
Entity type:Organization
Organization Name:TSAFACK RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RONELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DONGMO
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:602-465-2569
Mailing Address - Street 1:7507 S 15TH LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-6929
Mailing Address - Country:US
Mailing Address - Phone:602-465-2569
Mailing Address - Fax:
Practice Address - Street 1:7507 S 15TH LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-6929
Practice Address - Country:US
Practice Address - Phone:602-465-2569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH7296OtherSTATE LICENSE