Healthcare Provider Details

I. General information

NPI: 1891312542
Provider Name (Legal Business Name): SEMPER FIDELIS BEHAVIORAL HEALTH CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8020 N 17TH DR
PHOENIX AZ
85021-5217
US

IV. Provider business mailing address

111 N DUPONT CIR UNIT 337
PHOENIX AZ
85034-1847
US

V. Phone/Fax

Practice location:
  • Phone: 480-430-5491
  • Fax:
Mailing address:
  • Phone: 480-430-5491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: NASSON NATHAN
Title or Position: ADMINISTRATION
Credential:
Phone: 860-308-3823