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General NPI Number Information
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NPI Number | 1457130676
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Entity Type | Organization
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Legal Business Name | KAIROS MOMENT HEALTHCARE AND BEHAVIORAL CLINIC - LLC
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Dates
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Enumeration Date | 09/26/2023
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Last Update Date | 10/28/2024
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Provider Practice Location Address
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Address Line | 9652 W PATRICK LN
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City | PEORIA
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State | AZ
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Zip | 85383-4319
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Country | US
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Telephone | 602-410-0958
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Fax |
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Provider Business Mailing Address
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Address Line | 9652 W PATRICK LN
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City | PEORIA
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State | AZ
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Zip | 85383-4319
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Country | US
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Telephone | 602-410-0958
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | ADESOLA IZASOMEH
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Credential | PMHNP - BC
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Telephone | 602-410-0958
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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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 | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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