Healthcare Provider Details

I. General information

NPI: 1942894761
Provider Name (Legal Business Name): RESILIENT COMMUNITY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2021
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5039 N 57TH AVE APT 252
GLENDALE AZ
85301-7461
US

IV. Provider business mailing address

5039 N 57TH AVE APT 252
GLENDALE AZ
85301-7461
US

V. Phone/Fax

Practice location:
  • Phone: 708-541-5006
  • Fax:
Mailing address:
  • Phone: 708-541-5006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: THERESA NICHOLAS
Title or Position: OWNER
Credential:
Phone: 708-541-5006