Provider Demographics
NPI:1568804342
Name:101 WALL SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:101 WALL SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:CHRISTAIN
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-285-9426
Mailing Address - Street 1:919 N STAPLEY DR
Mailing Address - Street 2:SUITE M
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-5639
Mailing Address - Country:US
Mailing Address - Phone:480-285-9426
Mailing Address - Fax:480-907-1358
Practice Address - Street 1:919 N STAPLEY DR
Practice Address - Street 2:SUITE M
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-5639
Practice Address - Country:US
Practice Address - Phone:480-285-9426
Practice Address - Fax:480-907-1358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-4204251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health