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General NPI Number Information
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NPI Number | 1619457785
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Entity Type | Organization
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Legal Business Name | SHALOM BEHAVIORAL CARE LLC
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Dates
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Enumeration Date | 08/18/2018
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Last Update Date | 08/28/2018
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Provider Practice Location Address
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Address Line | 35301 N BELGIAN BLUE CT
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City | SAN TAN VALLEY
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State | AZ
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Zip | 85143
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Country | US
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Telephone | 480-687-0462
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Fax |
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Provider Business Mailing Address
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Address Line | 35301 N BELGIAN BLUE CT
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City | SAN TAN VALLEY
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State | AZ
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Zip | 85143-5497
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Country | US
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Telephone | 480-687-0462
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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 | ANTHONY VINCENT OLORUNSOLA
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Credential | FNP -BC
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Telephone | 623-806-6864
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 | BH5490
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License Number State | AZ
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