Provider Demographics
NPI:1568740801
Name:JUSSAMAL MANOR
Entity Type:Organization
Organization Name:JUSSAMAL MANOR
Other - Org Name:0
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:NJUGUNA
Authorized Official - Last Name:MARIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-567-6673
Mailing Address - Street 1:1302 W KESLER LN
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-7286
Mailing Address - Country:US
Mailing Address - Phone:951-567-6673
Mailing Address - Fax:480-268-7738
Practice Address - Street 1:3047 E KINGBIRD PL
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286-5615
Practice Address - Country:US
Practice Address - Phone:480-268-7738
Practice Address - Fax:480-268-7738
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUSSAMAL MANOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH3838320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness