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General NPI Number Information
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NPI Number | 1811618051
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Entity Type | Organization
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Legal Business Name | BALM OF GILEAD LLC
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Dates
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Enumeration Date | 09/07/2022
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Last Update Date | 09/07/2022
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Provider Practice Location Address
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Address Line | 15106 W SELLS DR
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City | GOODYEAR
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State | AZ
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Zip | 85395-7702
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Country | US
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Telephone | 480-746-9776
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Fax |
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Provider Business Mailing Address
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Address Line | 15106 W SELLS DR
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City | GOODYEAR
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State | AZ
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Zip | 85395-7702
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ORGANIZER
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Name | AUSTIN EZENWA
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Credential |
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Telephone | 949-690-2305
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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