Provider Demographics
NPI:1720650583
Name:SHALOM BEHAVIORAL CARE LLC
Entity Type:Organization
Organization Name:SHALOM BEHAVIORAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STATUTORY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:OLORUNSOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-806-6864
Mailing Address - Street 1:10612 E MARIGOLD LN
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AZ
Mailing Address - Zip Code:85132-7320
Mailing Address - Country:US
Mailing Address - Phone:480-684-2004
Mailing Address - Fax:
Practice Address - Street 1:10612 E MARIGOLD LN
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85132-7320
Practice Address - Country:US
Practice Address - Phone:480-684-2004
Practice Address - Fax:480-582-6043
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHALOM BEHAVIORAL CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility