Provider Demographics
NPI:1306604475
Name:KONKRETE ROSE YOUTH AND FAMILY SERVICES LLC
Entity type:Organization
Organization Name:KONKRETE ROSE YOUTH AND FAMILY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAURYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAY
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:602-552-2381
Mailing Address - Street 1:929 N VAL VISTA DR STE 109-1197
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-3706
Mailing Address - Country:US
Mailing Address - Phone:602-552-2381
Mailing Address - Fax:
Practice Address - Street 1:3707 E SOUTHERN AVE STE 2054
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6217
Practice Address - Country:US
Practice Address - Phone:602-552-2381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health