MEDICARE: PRIME CARE RESIDENTIAL AND BEHAVIORAL SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1801744065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME CARE RESIDENTIAL AND BEHAVIORAL SERVICES

Provider Business Mailing Address
First Line	:	6565 N 17TH AVE APT 11
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-1330
Country	:	US
Telephone Number	:	801-815-3521
Fax Number	:

Provider Business Practice Location Address
First Line	:	6565 N 17TH AVE APT 11
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-1330
Country	:	US
Telephone Number	:	801-815-3521
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MATILDA NAMUCHANA MASUMBA
Credential	:
Telephone Number	:	801-815-3521

Provider Enumeration Date	:	03/21/2026
Last Update Date	:	03/21/2026

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