Provider Demographics
NPI:1902613888
Name:TASSILIMAN HOUSE LLC
Entity type:Organization
Organization Name:TASSILIMAN HOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:KALLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-884-3162
Mailing Address - Street 1:502 N 112TH DR
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-7902
Mailing Address - Country:US
Mailing Address - Phone:623-248-9448
Mailing Address - Fax:
Practice Address - Street 1:7419 W DARROW ST
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2644
Practice Address - Country:US
Practice Address - Phone:623-248-9448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-14
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness