Healthcare Provider Details

I. General information

NPI: 1457130676
Provider Name (Legal Business Name): KAIROS MOMENT HEALTHCARE AND BEHAVIORAL CLINIC - LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 10/28/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9652 W PATRICK LN
PEORIA AZ
85383-4319
US

IV. Provider business mailing address

9652 W PATRICK LN
PEORIA AZ
85383-4319
US

V. Phone/Fax

Practice location:
  • Phone: 602-410-0958
  • Fax:
Mailing address:
  • Phone: 602-410-0958
  • 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 Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ADESOLA IZASOMEH
Title or Position: NURSE PRACTITIONER
Credential: PMHNP - BC
Phone: 602-410-0958