1356780563 NPI number — BARAKA HOUSE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356780563 NPI number — BARAKA HOUSE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BARAKA HOUSE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356780563
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10000 N 31ST AVE STE A107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85051-9582
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-441-2388
Provider Business Mailing Address Fax Number:
800-881-7511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7445 W CHERYL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85345-6722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-878-0463
Provider Business Practice Location Address Fax Number:
623-878-0463
Provider Enumeration Date:
06/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
OKORIE
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
602-524-0824

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  BH4229 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3104A0625X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: BH4229 . This is a "BEHAVIORAL HEALTH LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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