Healthcare Provider Details

I. General information

NPI: 1952717654
Provider Name (Legal Business Name): TOLLESON HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10314 W SUPERIOR AVE
TOLLESON AZ
85353-8423
US

IV. Provider business mailing address

10314 W SUPERIOR AVE
TOLLESON AZ
85353-8423
US

V. Phone/Fax

Practice location:
  • Phone: 602-330-2203
  • Fax:
Mailing address:
  • Phone: 602-330-2203
  • Fax: 623-792-7488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberAL9017H
License Number StateAZ

VIII. Authorized Official

Name: MR. IFFA DIRIBA WOLKABA
Title or Position: OWNER
Credential: SOCIAL WORKER
Phone: 602-330-2203