MEDICARE: CHOLLA BEHAVIORAL HEALTH LLC

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	320800000X	Mental Illness Community Based Residential Treatment Facility
2	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1982566584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHOLLA BEHAVIORAL HEALTH LLC

Provider Business Mailing Address
First Line	:	9201 N 25TH AVE STE 185
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-2717
Country	:	US
Telephone Number	:	602-686-5779
Fax Number	:

Provider Business Practice Location Address
First Line	:	5924 W HEDGEHOG PL
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85083-6558
Country	:	US
Telephone Number	:	602-686-5779
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JERICHO CHEBULTZ
Credential	:
Telephone Number	:	602-686-5779

Provider Enumeration Date	:	12/02/2025
Last Update Date	:	04/21/2026

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