Healthcare Provider Details

I. General information

NPI: 1922678416
Provider Name (Legal Business Name): PASTALINO MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4929 E LAUREL LN
SCOTTSDALE AZ
85254-4640
US

IV. Provider business mailing address

1383 W KESLER LN
CHANDLER AZ
85224-7289
US

V. Phone/Fax

Practice location:
  • Phone: 951-236-4717
  • Fax: 480-664-7668
Mailing address:
  • Phone: 951-236-4717
  • Fax: 480-664-7668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: PAUL MUNYAO KIVILA SR.
Title or Position: CEO
Credential: BA
Phone: 480-634-5485