Provider Demographics
NPI:1891558946
Name:BENEDICTA HOUSE
Entity Type:Organization
Organization Name:BENEDICTA HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AIME
Authorized Official - Middle Name:MUKURA LINDA
Authorized Official - Last Name:MINEGA SHABANI
Authorized Official - Suffix:
Authorized Official - Credentials:BHT
Authorized Official - Phone:602-477-9416
Mailing Address - Street 1:11063 W VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-5889
Mailing Address - Country:US
Mailing Address - Phone:602-477-9416
Mailing Address - Fax:
Practice Address - Street 1:3349 E CAMBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-1215
Practice Address - Country:US
Practice Address - Phone:602-477-9416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHALOM BEHAVIORAL HOUSE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health