Healthcare Provider Details

I. General information

NPI: 1871172536
Provider Name (Legal Business Name): MILESTONE RECOVERY TRANSITIONAL LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7340 W BETHANY HOME RD
GLENDALE AZ
85303-4321
US

IV. Provider business mailing address

8751 N 51ST AVE STE 108
GLENDALE AZ
85302-4943
US

V. Phone/Fax

Practice location:
  • Phone: 520-329-3283
  • Fax:
Mailing address:
  • Phone: 602-421-6667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: WELLENGTEN JENKINS
Title or Position: MEMBER-MANAGER
Credential:
Phone: 602-421-6667