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1104413863 NPI number — STARGATE BEHAVIORAL HEALTH SERVICES LLC

NPI Number: 1104413863
Health Care Provider/Practitioner: STARGATE BEHAVIORAL HEALTH SERVICES LLC

Information about “1104413863” NPI (STARGATE BEHAVIORAL HEALTH SERVICES LLC) exists in 1104413863 in HTML format HTML  |  1104413863 in plain Text format TXT  |  1104413863 in PDF (Portable Document Format) PDF  |  1104413863 in an XML format XML  formats.

NPI Number : 1104413863 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1104413863",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "Y",
    "ParentOrgLBN": "-",
    "ParentOrgTIN": null,
    "OrgName": "STARGATE BEHAVIORAL HEALTH SERVICES LLC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "7346 N 72ND AVE",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "GLENDALE",
    "MailingAddressStateName": "AZ",
    "MailingAddressPostalCode": "85303-1602",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "216-630-9350",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "7346 N 72ND AVE",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "GLENDALE",
    "PracticeLocationAddressStateName": "AZ",
    "PracticeLocationAddressPostalCode": "85303-1602",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "216-630-9350",
    "PracticeLocationAddressFaxNumber": "602-581-3000",
    "EnumerationDate": "12/29/2020",
    "LastUpdateDate": "12/29/2020",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "DONZO",
    "AuthorizedOfficialFirstName": "SEKOU",
    "AuthorizedOfficialMiddleName": "A",
    "AuthorizedOfficialTitle": "CO OWNER/ADMINISTRATOR",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "MALIKEE SONIE",
    "AuthorizedOfficialTelephoneNumber": "216-630-9350",
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "251S00000X",
        "TaxonomyName": "Community/Behavioral Health Agency",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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