Provider Demographics
NPI:1669244760
Name:PHOENIX RESIDENTIAL BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:PHOENIX RESIDENTIAL BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:USMAN
Authorized Official - Middle Name:JAWA
Authorized Official - Last Name:BUNDU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:148-097-7945
Mailing Address - Street 1:3555 N SAILBOAT LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-3620
Mailing Address - Country:US
Mailing Address - Phone:480-977-9457
Mailing Address - Fax:
Practice Address - Street 1:3555 N SAILBOAT LN
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-3620
Practice Address - Country:US
Practice Address - Phone:480-977-9457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health