Healthcare Provider Details

I. General information

NPI: 1962155739
Provider Name (Legal Business Name): BETHEL HILLS INTEGRATED HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 02/01/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13838 S 46TH PL STE 340
PHOENIX AZ
85044-7805
US

IV. Provider business mailing address

13838 S 46TH PL STE 340
PHOENIX AZ
85044-7805
US

V. Phone/Fax

Practice location:
  • Phone: 480-597-7903
  • Fax: 480-597-7904
Mailing address:
  • Phone: 480-597-7903
  • Fax: 480-597-7904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateNULL
# 7
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number StateNULL

VIII. Authorized Official

Name: OLUBUKOLA KOMOLAFE
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 832-542-3181