Healthcare Provider Details

I. General information

NPI: 1780127241
Provider Name (Legal Business Name): STEVEN ILLERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2016
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3854 HEATHER AVE
KINGMAN AZ
86401-3844
US

IV. Provider business mailing address

3854 HEATHER AVE
KINGMAN AZ
86401-3844
US

V. Phone/Fax

Practice location:
  • Phone: 702-219-0881
  • Fax: 928-774-2159
Mailing address:
  • Phone: 805-868-7581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number8122828
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number8122828
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: