Idris Roberson

Primary specialty

Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityTaxonomy code 320900000X

License

221509-14979 Issued in AZ

Practice address

4494 W Peoria Ave Ste 101
Glendale, AZ 85302-2024

Phone

(602) 687-2043

Fax

(623) 440-4285

NPI assigned

Sep 15, 2023

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Triumph Care Group

  • Day Training/Habilitation Specialist
  • Glendale, AZ
  • NPI 1497510887
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1694736000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1694736000000",
    "number": "1639957277",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4494 W PEORIA AVE STE 101",
            "city": "GLENDALE",
            "state": "AZ",
            "postal_code": "853022024",
            "telephone_number": "602-687-2043",
            "fax_number": "623-440-4285"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4494 W PEORIA AVE STE 101",
            "city": "GLENDALE",
            "state": "AZ",
            "postal_code": "853022024",
            "telephone_number": "602-687-2043",
            "fax_number": "623-440-4285"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ROBERSON",
        "first_name": "IDRIS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2023-09-15",
        "last_updated": "2023-09-15",
        "certification_date": "2023-09-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "AZ",
            "license": "221509-14979",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Roadrunner Medical Transportation Service
• Roadrunner Oxygen Service, Inc.
• Audra Robbins
• Riley Robbins
• Betsy Robello, LMT
• Robert a. Block PHD PC
• Robert L. Critchfield DDS PC
• Robert Rubenzik, MDPC
• Bradley Scott Roberts, DDS
• Cory Roberts, LPC

• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Glendale, AZ
• Providers in Glendale, AZ by specialty
• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 15, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.