MEDICARE: HEALVINE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	106S00000X	Behavior Technician
2	324500000X	Substance Abuse Rehabilitation Facility
3	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1396413720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALVINE LLC

Provider Business Mailing Address
First Line	:	1204 E BASELINE RD STE 106
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85283-1447
Country	:	US
Telephone Number	:	877-755-8040
Fax Number	:

Provider Business Practice Location Address
First Line	:	1204 E BASELINE RD STE 106
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85283-1447
Country	:	US
Telephone Number	:	877-755-8040
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MOHAMED OTHMAN
Credential	:
Telephone Number	:	602-815-3293

Provider Enumeration Date	:	08/31/2021
Last Update Date	:	08/16/2022

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Directions to “HEALVINE LLC ” Practice Location

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