Healthcare Provider Details

I. General information

NPI: 1972119733
Provider Name (Legal Business Name): ACOMA BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3437 W ACOMA DR
PHOENIX AZ
85053-5620
US

IV. Provider business mailing address

3437 W ACOMA DR
PHOENIX AZ
85053-5620
US

V. Phone/Fax

Practice location:
  • Phone: 602-888-6779
  • Fax:
Mailing address:
  • Phone: 602-888-6779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: RWABUNEZA VIOLET MUSTARI
Title or Position: CEO
Credential:
Phone: 949-449-4140