Healthcare Provider Details

I. General information

NPI: 1114690468
Provider Name (Legal Business Name): WILSHIRE HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2021
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8809 W WILSHIRE DR
PHOENIX AZ
85037-3641
US

IV. Provider business mailing address

8809 W WILSHIRE DR
PHOENIX AZ
85037-3641
US

V. Phone/Fax

Practice location:
  • Phone: 602-802-4209
  • Fax:
Mailing address:
  • Phone:
  • 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 Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JANIS NTOUKAM
Title or Position: MANAGER
Credential:
Phone: 602-802-4209