Provider Demographics
NPI:1386969947
Name:SAN JUDAS GROUP HOME
Entity type:Organization
Organization Name:SAN JUDAS GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IMELDA MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:NORIEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-643-5932
Mailing Address - Street 1:5415 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-4000
Mailing Address - Country:US
Mailing Address - Phone:602-643-5932
Mailing Address - Fax:602-281-6974
Practice Address - Street 1:5116 S 11TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-2363
Practice Address - Country:US
Practice Address - Phone:602-643-5932
Practice Address - Fax:602-281-6974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH6076320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ203799Medicaid