Healthcare Provider Details

I. General information

NPI: 1295269009
Provider Name (Legal Business Name): COMFORT BEHAVIOR HEALTH RESIDENTIAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 08/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14235 N 28TH ST
PHOENIX AZ
85032-5040
US

IV. Provider business mailing address

14235 N 28TH ST
PHOENIX AZ
85032-5040
US

V. Phone/Fax

Practice location:
  • Phone: 602-923-8428
  • Fax: 602-923-8428
Mailing address:
  • Phone: 602-923-8428
  • Fax: 602-923-8428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBH5110
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberBH5110
License Number StateAZ

VIII. Authorized Official

Name: EDUARD MALETA
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 602-923-8428