=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861932097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKA-SHIFRA FACILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2017
-----------------------------------------------------
Last Update Date | 03/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7136 N 73RD DR
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85303-2569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-545-0242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7136 N 73RD DR
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85303-2569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ CEO
-----------------------------------------------------
Name | BOB KABAMBA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-545-0242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | BH4983
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------