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General NPI Number Information
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NPI Number | 1043028673
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Entity Type | Organization
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Legal Business Name | WESTSIDE BEHAVIORAL HEALTH LLC
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Dates
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Enumeration Date | 12/30/2024
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Last Update Date | 12/30/2024
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Provider Practice Location Address
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Address Line | 853 PALA MESA DR
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City | KINGMAN
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State | AZ
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Zip | 86409-3923
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Country | US
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Telephone | 928-279-2661
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Fax |
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Provider Business Mailing Address
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Address Line | 853 PALA MESA DR
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City | KINGMAN
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State | AZ
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Zip | 86409-3923
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Country | US
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Telephone | 928-279-2661
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. TII MAMBILLA
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Credential | MD
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Telephone | 928-279-2661
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number |
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License Number State |
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