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General NPI Number Information
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NPI Number | 1265949861
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Entity Type | Organization
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Legal Business Name | DESTINY BEHAVIORAL HEALTH RESIDENTIAL CARE LLC 5
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Dates
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Enumeration Date | 01/04/2018
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Last Update Date | 01/04/2018
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Provider Practice Location Address
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Address Line | 10313 W HESS STREET
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City | TOLLESON
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State | AZ
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Zip | 85353
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Country | US
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Telephone | 602-384-8820
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Fax | 623-435-6566
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Provider Business Mailing Address
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Address Line | 2911 SOUTH 87TH DRIVE
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City | TOLLESON
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State | AZ
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Zip | 85353
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Country | US
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Telephone | 602-384-8820
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Fax | 623-435-6566
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MR. FUNSO FEYI OGUNLA
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Credential |
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Telephone | 602-384-8820
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | BH5356
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License Number State | AZ
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