MEDICARE: AVRA VALLEY RELIANCE BEHAVIORAL HOME 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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1649998691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVRA VALLEY RELIANCE BEHAVIORAL HOME LLC

Provider Business Mailing Address
First Line	:	2162 W SPEEDWAY BLVD APT 31104
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85745-3938
Country	:	US
Telephone Number	:	978-729-2869
Fax Number	:

Provider Business Practice Location Address
First Line	:	1621 N SILVERBELL RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85745-1816
Country	:	US
Telephone Number	:	520-622-0488
Fax Number	:	520-889-4536

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. CATHERINE KAMWITHI
Credential	:
Telephone Number	:	520-624-4475

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

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