Provider Demographics
NPI:1659727816
Name:MWANGAZA RESIDENTIAL CARE LLC
Entity Type:Organization
Organization Name:MWANGAZA RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JONAH
Authorized Official - Middle Name:KIBITOK
Authorized Official - Last Name:MAIYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-248-1295
Mailing Address - Street 1:8618 N. WESTERN JUNIPER TERACCE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85743
Mailing Address - Country:US
Mailing Address - Phone:520-248-1295
Mailing Address - Fax:520-338-2490
Practice Address - Street 1:8421 E. COLETTE ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710
Practice Address - Country:US
Practice Address - Phone:520-398-5674
Practice Address - Fax:520-305-3837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-4900320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness