Healthcare Provider Details

I. General information

NPI: 1295323095
Provider Name (Legal Business Name): ANGEL HEART BEHAVIORAL HEALTH V , LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2021
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 S 103RD DR
TOLLESON AZ
85353-4187
US

IV. Provider business mailing address

3909 S 103RD DR
TOLLESON AZ
85353-4187
US

V. Phone/Fax

Practice location:
  • Phone: 207-409-6515
  • Fax:
Mailing address:
  • Phone: 207-409-6515
  • Fax: 623-777-0082

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: MR. ERIC NIBIZI SR.
Title or Position: CEO
Credential:
Phone: 207-409-6515