=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720639552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW HOPE BEHAVIORAL RESIDENCY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2019
-----------------------------------------------------
Last Update Date | 09/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 424 E DIAMOND TRL
-----------------------------------------------------
City | SAN TAN VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85143-5872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-233-7786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2358 E SPRUCE DR
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85286-1565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JUDE NWANKWO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-380-2532
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------