Healthcare Provider Details

I. General information

NPI: 1114552122
Provider Name (Legal Business Name): ANGEL HEART BEHAVIORAL HEALTH III LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9223 W MEADOW BROOK 9223 W MEADOW BROOK AVE
PHOENIX AZ
85037-8503
US

IV. Provider business mailing address

9223 W MEADOWBROOK AVE
PHOENIX AZ
85037-2442
US

V. Phone/Fax

Practice location:
  • Phone: 207-409-6515
  • Fax:
Mailing address:
  • Phone: 207-409-6515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: AIMEE NYIRAKANYANA
Title or Position: PROGRAM OPERATING OFFICER
Credential:
Phone: 623-777-0427