Healthcare Provider Details

I. General information

NPI: 1104580596
Provider Name (Legal Business Name): SEEDS OF LOVE 1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2021
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2928 S 97TH LN
TOLLESON AZ
85353-8525
US

IV. Provider business mailing address

2701 N 16TH ST STE 108
PHOENIX AZ
85006-1264
US

V. Phone/Fax

Practice location:
  • Phone: 319-202-2573
  • Fax: 623-777-0082
Mailing address:
  • Phone: 319-202-2573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. AIMABLE SEBA BYISHIMO
Title or Position: OWNER
Credential:
Phone: 319-202-2573