Healthcare Provider Details

I. General information

NPI: 1891701280
Provider Name (Legal Business Name): MIKID, MENTALLY ILL KIDS IN DISTRESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 E WILLETTA ST STE. 128
PHOENIX AZ
85006-2723
US

IV. Provider business mailing address

755 E WILLETTA ST STE. 128
PHOENIX AZ
85006-2723
US

V. Phone/Fax

Practice location:
  • Phone: 602-253-1240
  • Fax: 602-253-1250
Mailing address:
  • Phone: 602-253-1240
  • Fax: 602-253-1250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License NumberCSA05CP0172
License Number StateAZ

VIII. Authorized Official

Name: JEFF KAZMIERCZAK
Title or Position: EXECUTIVE DIRECTOR
Credential: RN,MSN,MBA
Phone: 602-253-1240