Healthcare Provider Details

I. General information

NPI: 1073349874
Provider Name (Legal Business Name): NEW MERVEILLE 2 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4821 N 108TH AVE
PHOENIX AZ
85037-5471
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 Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. DESIRE N NKOMEZI
Title or Position: OWNER
Credential: PHD
Phone: 817-707-2798