Healthcare Provider Details

I. General information

NPI: 1497338891
Provider Name (Legal Business Name): BANSA ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 S DESERT STEPPES DR
TUCSON AZ
85710-5940
US

IV. Provider business mailing address

6788 S SONORAN BLOOM AVE
TUCSON AZ
85756-3040
US

V. Phone/Fax

Practice location:
  • Phone: 520-440-1412
  • Fax:
Mailing address:
  • Phone: 520-440-1412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: PRUDENTIA TAKU
Title or Position: OWNER
Credential:
Phone: 520-440-1412