Provider Demographics
NPI:1770931966
Name:JUSSAMAL MANOR 11
Entity type:Organization
Organization Name:JUSSAMAL MANOR 11
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO./PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:NJUGUNA
Authorized Official - Last Name:MARIRA
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:480-570-6245
Mailing Address - Street 1:641 S. KAREN DR.
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224
Mailing Address - Country:US
Mailing Address - Phone:480-621-8640
Mailing Address - Fax:480-257-3447
Practice Address - Street 1:641 S. KAREN DR.
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224
Practice Address - Country:US
Practice Address - Phone:480-621-8640
Practice Address - Fax:480-257-3447
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUSSAMAL MANOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4726320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness