Organization
TSAFACK RESIDENTIAL CARE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RONELLE DONGMO LPN (PROGRAM DIRECTOR/ADMINISTRATOR)
(602) 465-2569
Entity
Organization
Contact information
Practice address
7507 S 15TH LN, PHOENIX, AZ 85041-6929
(602) 465-2569
Mailing address
7507 S 15TH LN, PHOENIX, AZ 85041-6929
(602) 465-2569
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
BH7296
STATE LICENSE
AZ
Enumeration date
06/03/2022
Last updated
06/03/2022
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