Provider Demographics
NPI:1841525151
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:04/05/1979
Authorized Official - Phone:520-248-1295
Mailing Address - Street 1:2234 E CALLE SIERRA DEL MANANTIAL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85706-5052
Mailing Address - Country:US
Mailing Address - Phone:520-207-9283
Mailing Address - Fax:520-207-9283
Practice Address - Street 1:2234 E CALLE SIERRA DEL MANANTIAL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85706-5052
Practice Address - Country:US
Practice Address - Phone:520-207-9283
Practice Address - Fax:520-207-9283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3425320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness