Healthcare Provider Details

I. General information

NPI: 1457997280
Provider Name (Legal Business Name): VILLAGE MENTORS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4903 E DIXON CIR
MESA AZ
85205-6453
US

IV. Provider business mailing address

4903 E DIXON CIR
MESA AZ
85205-6453
US

V. Phone/Fax

Practice location:
  • Phone: 480-313-4770
  • Fax:
Mailing address:
  • Phone: 480-313-4770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: JERMAINE JORDAN
Title or Position: CEO
Credential: MBA
Phone: 480-313-4770