Provider Demographics
NPI:1679704381
Name:EUREKA IMPERIAL RESIDENCE
Entity type:Organization
Organization Name:EUREKA IMPERIAL RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:EBAI
Authorized Official - Last Name:TANYI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-375-5192
Mailing Address - Street 1:7110 S CHAMPAGNE WAY
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-9122
Mailing Address - Country:US
Mailing Address - Phone:480-375-5192
Mailing Address - Fax:480-821-7860
Practice Address - Street 1:1740 S HERITAGE DRIVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296
Practice Address - Country:US
Practice Address - Phone:480-264-2647
Practice Address - Fax:480-264-2647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH3319320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness