1376623769 NPI number — ARIZONA BEHAVIORAL HOME HEALTH

Table of content: CRYSTAL GAIL KUEBLER M.P.T. (NPI 1699000109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376623769 NPI number — ARIZONA BEHAVIORAL HOME HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARIZONA BEHAVIORAL HOME HEALTH
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:
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:
1376623769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4225 W GLENDALE AVE
Provider Second Line Business Mailing Address:
SUITE E119
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85051-8194
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-915-0270
Provider Business Mailing Address Fax Number:
623-915-0280

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1349 E COLTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85014-3048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-915-0270
Provider Business Practice Location Address Fax Number:
623-915-0280
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BONNACCI
Authorized Official First Name:
CARL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
623-915-0270

Provider Taxonomy Codes

  • Taxonomy code: 103TB0200X , with the licence number:  3376 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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