MEDICARE: BENCHMARK VALLEY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265067052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BENCHMARK VALLEY LLC

Provider Business Mailing Address
First Line	:	5625 W EUCLID AVE
Second Line	:
City	:	LAVEEN
State	:	AZ
Zip	:	85339-5247
Country	:	US
Telephone Number	:	858-386-6705
Fax Number	:

Provider Business Practice Location Address
First Line	:	7321 S 15TH DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-6932
Country	:	US
Telephone Number	:	858-386-6705
Fax Number	:	602-603-3981

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TITUS KIMANI MWANGI
Credential	:
Telephone Number	:	858-386-6705

Provider Enumeration Date	:	03/12/2020
Last Update Date	:	03/12/2020

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Directions to “BENCHMARK VALLEY LLC ” Practice Location

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