Provider Demographics
NPI:1346997392
Name:RISING STAR BEHAVIOR HEALTH LLC
Entity Type:Organization
Organization Name:RISING STAR BEHAVIOR HEALTH LLC
Other - Org Name:RISING STAR BEHAVIOR HEALTH LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:ADDEI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-814-4693
Mailing Address - Street 1:546 E PASTURE CANYON DR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5814
Mailing Address - Country:US
Mailing Address - Phone:602-814-4693
Mailing Address - Fax:480-452-0828
Practice Address - Street 1:546 E PASTURE CANYON DR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-5814
Practice Address - Country:US
Practice Address - Phone:720-499-8868
Practice Address - Fax:480-452-0828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH7360Medicaid