Provider Demographics
NPI:1679092506
Name:EUREKA IMPERIAL RESIDENCE 3
Entity type:Organization
Organization Name:EUREKA IMPERIAL RESIDENCE 3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:TANYI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-264-2647
Mailing Address - Street 1:1080 E CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1135
Mailing Address - Country:US
Mailing Address - Phone:480-264-2647
Mailing Address - Fax:
Practice Address - Street 1:1080 E CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1135
Practice Address - Country:US
Practice Address - Phone:480-264-2647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EUREKA IMPERIAL RESIDENCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness