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General NPI Number Information
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NPI Number | 1891701280
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Entity Type | Organization
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Legal Business Name | MIKID, MENTALLY ILL KIDS IN DISTRESS
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Dates
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Enumeration Date | 07/31/2006
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Last Update Date | 08/14/2024
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Provider Practice Location Address
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Address Line | 755 E WILLETTA ST STE. 128
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City | PHOENIX
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State | AZ
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Zip | 85006-2723
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Country | US
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Telephone | 602-253-1240
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Fax | 602-253-1250
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Provider Business Mailing Address
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Address Line | 755 E WILLETTA ST STE. 128
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City | PHOENIX
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State | AZ
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Zip | 85006-2723
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Country | US
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Telephone | 602-253-1240
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Fax | 602-253-1250
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | JEFF KAZMIERCZAK
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Credential | RN,MSN,MBA
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Telephone | 602-253-1240
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number | CSA05CP0172
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License Number State | AZ
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