Healthcare Provider Details

I. General information

NPI: 1245860683
Provider Name (Legal Business Name): JMJ ENTERPISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14547 W ACAPULCO LN
SURPRISE AZ
85379-8548
US

IV. Provider business mailing address

14804 N 130TH LN
EL MIRAGE AZ
85335-3436
US

V. Phone/Fax

Practice location:
  • Phone: 623-428-4429
  • Fax:
Mailing address:
  • Phone: 623-428-4429
  • 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: JOSEPH EZELL
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-628-7207