Healthcare Provider Details

I. General information

NPI: 1326432741
Provider Name (Legal Business Name): PASTALINO MANOR LLC 2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1383 W KESLER LN
CHANDLER AZ
85224-7289
US

IV. Provider business mailing address

1393 W KESLER LN
CHANDLER AZ
85224-7229
US

V. Phone/Fax

Practice location:
  • Phone: 480-634-5485
  • Fax: 480-699-7288
Mailing address:
  • Phone: 480-634-5485
  • Fax: 480-699-7288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBH 4431
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberBH 4431
License Number StateAZ

VIII. Authorized Official

Name: MR. PAUL MUNYAO KIVILA
Title or Position: ADMINISTRATOR
Credential: BA
Phone: 480-634-5485