MEDICARE: JUSSAMAL MANOR 11

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	BH4726	AZ

General Provider Information

NPI Number	:	1770931966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUSSAMAL MANOR 11

Provider Business Mailing Address
First Line	:	641 S. KAREN DR.
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85224
Country	:	US
Telephone Number	:	480-621-8640
Fax Number	:	480-257-3447

Provider Business Practice Location Address
First Line	:	641 S. KAREN DR.
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85224
Country	:	US
Telephone Number	:	480-621-8640
Fax Number	:	480-257-3447

Authorized Official
Title or Position	:	CEO./PROGRAM DIRECTOR
Name	:	MR. SAMUEL NJUGUNA MARIRA
Credential	:	CEO.
Telephone Number	:	480-570-6245

Provider Enumeration Date	:	05/27/2016
Last Update Date	:	05/27/2016

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