Healthcare Provider Details

I. General information

NPI: 1649194846
Provider Name (Legal Business Name): FILLMORE STREET UNIT A WELLNESS HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11373 N 117TH ST
SCOTTSDALE AZ
85259-4130
US

IV. Provider business mailing address

11373 N 117TH ST
SCOTTSDALE AZ
85259-4130
US

V. Phone/Fax

Practice location:
  • Phone: 480-225-4012
  • Fax:
Mailing address:
  • Phone: 480-740-7442
  • 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

VIII. Authorized Official

Name: SANJNA KOHLI
Title or Position: MANAGING MEMBER
Credential:
Phone: 480-225-4012