Healthcare Provider Details

I. General information

NPI: 1598473290
Provider Name (Legal Business Name): D&G PROVIDENCE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2022
Last Update Date: 11/10/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9186 W JOHN CABOT RD
PEORIA AZ
85382-7716
US

IV. Provider business mailing address

9186 W JOHN CABOT RD
PEORIA AZ
85382-7716
US

V. Phone/Fax

Practice location:
  • Phone: 480-285-5907
  • Fax:
Mailing address:
  • Phone: 480-285-5907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
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: DOUGLAS GASORE KABUNDA
Title or Position: MANAGER
Credential:
Phone: 480-285-5907