=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780375287
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CRUSADER CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2023
-----------------------------------------------------
Last Update Date | 05/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4480 W PEORIA AVE STE 105
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85302-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-271-2624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4480 W PEORIA AVE STE 105
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85302-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-271-2624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | KENYATTA FLETCHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-271-2624
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------