Healthcare Provider Details

I. General information

NPI: 1710749288
Provider Name (Legal Business Name): NEW MERVEILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 E CAMELBACK RD STE 600
PHOENIX AZ
85016-3493
US

IV. Provider business mailing address

4821 N 108TH AVE
PHOENIX AZ
85037-5471
US

V. Phone/Fax

Practice location:
  • Phone: 817-707-2798
  • Fax:
Mailing address:
  • Phone: 817-707-2798
  • 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 Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DESIRE NKOMEZI
Title or Position: OWNER
Credential:
Phone: 817-707-2798