Healthcare Provider Details

I. General information

NPI: 1588176697
Provider Name (Legal Business Name): GOLDEN CROSS HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2017
Last Update Date: 10/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1523 W COLTER ST APT 6
PHOENIX AZ
85015-3013
US

IV. Provider business mailing address

1523 W COLTER ST UNIT 44
PHOENIX AZ
85015-3012
US

V. Phone/Fax

Practice location:
  • Phone: 602-583-7534
  • Fax: 602-583-7541
Mailing address:
  • Phone: 602-583-7534
  • Fax: 602-583-7541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: LUCIA AJAYI
Title or Position: MANAGER
Credential:
Phone: 240-374-2584