Provider Demographics
NPI:1114552122
Name:ANGEL HEART BEHAVIORAL HEALTH III LLC
Entity Type:Organization
Organization Name:ANGEL HEART BEHAVIORAL HEALTH III LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:
Authorized Official - Last Name:NYIRAKANYANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-777-0427
Mailing Address - Street 1:9223 W MEADOWBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-2442
Mailing Address - Country:US
Mailing Address - Phone:207-409-6515
Mailing Address - Fax:
Practice Address - Street 1:9223 W MEADOW BROOK
Practice Address - Street 2:9223 W MEADOW BROOK AVE
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-8503
Practice Address - Country:US
Practice Address - Phone:207-409-6515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ003Medicaid
AZ0000OtherNO OTHER IDENTIFICATION NUMBER AVAILABLE