Healthcare Provider Details

I. General information

NPI: 1962181024
Provider Name (Legal Business Name): CHOSEN BEHAVIORAL HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 05/25/2024
Certification Date: 05/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15639 N VERDE ST
SURPRISE AZ
85378-4168
US

IV. Provider business mailing address

15639 N VERDE ST
SURPRISE AZ
85378-4168
US

V. Phone/Fax

Practice location:
  • Phone: 623-248-4100
  • Fax:
Mailing address:
  • Phone: 480-241-6853
  • 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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: SAB EDWARDS
Title or Position: OWNER
Credential:
Phone: 480-241-6853