Healthcare Provider Details

I. General information

NPI: 1194050278
Provider Name (Legal Business Name): OZAREE PLACE 1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 10/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7409 S 26TH LN
PHOENIX AZ
85041-6477
US

IV. Provider business mailing address

7409 S 26TH LN
PHOENIX AZ
85041-6477
US

V. Phone/Fax

Practice location:
  • Phone: 602-237-5584
  • Fax: 602-323-5021
Mailing address:
  • Phone: 602-237-5584
  • Fax: 602-323-5021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberBH3418
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberBH3418
License Number StateAZ

VIII. Authorized Official

Name: MR. FREDERICK ORLANDER JACOBS
Title or Position: OWNER/PROGRAM DIRECTOR
Credential:
Phone: 602-469-0802