=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689902801
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARIZONA FOUNDATION FOR SOCIAL JUSTICE CHILDREN AND YOUTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2009
-----------------------------------------------------
Last Update Date | 11/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18298 N JAMESON CT
-----------------------------------------------------
City | MARICOPA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85138-4627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-243-8893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18298 N JAMESON CT
-----------------------------------------------------
City | MARICOPA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85138-4627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-243-8893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | DR. SYLVESTER AJAGBE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-243-8893
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------