MEDICARE: SOUTH PHOENIX INTEGRITY HOUSE 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1619675626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH PHOENIX INTEGRITY HOUSE LLC

Provider Business Mailing Address
First Line	:	1612 E SOUTHERN AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-3534
Country	:	US
Telephone Number	:	520-907-1437
Fax Number	:

Provider Business Practice Location Address
First Line	:	1612 E SOUTHERN AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-3534
Country	:	US
Telephone Number	:	520-907-1437
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARA L CARLOS
Credential	:
Telephone Number	:	520-907-1437

Provider Enumeration Date	:	02/20/2023
Last Update Date	:	02/20/2023

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