Provider Demographics
NPI:1902558513
Name:DIAMOND GIRL ROCK DYNASTY NONPROFIT MUSIC ORGANIZATION
Entity Type:Organization
Organization Name:DIAMOND GIRL ROCK DYNASTY NONPROFIT MUSIC ORGANIZATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTONETTE
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-268-7813
Mailing Address - Street 1:7552 W WELDON AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033-3721
Mailing Address - Country:US
Mailing Address - Phone:480-280-3707
Mailing Address - Fax:
Practice Address - Street 1:7552 W WELDON AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-3721
Practice Address - Country:US
Practice Address - Phone:480-280-3707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No174200000XOther Service ProvidersMeals
No177F00000XOther Service ProvidersLodging
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ00000789345Medicaid
AZ00000789346OtherBLUECROSS BLUESHIELD
AZ00000789347OtherAETNA