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General NPI Number Information
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NPI Number | 1366101479
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Entity Type | Organization
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Legal Business Name | SHALOM BEHAVIORAL HOUSE, LLC
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Dates
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Enumeration Date | 12/16/2021
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Last Update Date | 12/16/2021
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Provider Practice Location Address
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Address Line | 11063 W VIRGINIA AVE
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City | AVONDALE
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State | AZ
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Zip | 85392-5889
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Country | US
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Telephone | 855-895-0261
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Fax | 855-755-9202
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Provider Business Mailing Address
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Address Line | 8050 N 19TH AVE UNIT 151
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City | PHOENIX
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State | AZ
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Zip | 85021-5160
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Country | US
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Telephone | 855-895-0261
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Fax | 855-755-9202
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Authorized Official
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Title or Position | MANAGER
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Name | MR. AIME MUKURA LINDA MINEGA SHABANI
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Credential | CNA/BHT
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Telephone | 855-895-0261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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