1922728088 NPI number — SHALOM INTEGRATED BEHAVIORAL CLINIC 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 1922728088 NPI number — SHALOM INTEGRATED BEHAVIORAL CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHALOM INTEGRATED BEHAVIORAL CLINIC 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:
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:
1922728088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
540 W IRON AVE STE 201-204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85210-6025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-304-8856
Provider Business Mailing Address Fax Number:
480-582-6043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 W IRON AVE STE 201-204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85210-6025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-304-8856
Provider Business Practice Location Address Fax Number:
480-582-6043
Provider Enumeration Date:
08/30/2022

Additional Information

Authorized Official

Authorized Official Last Name:
NYONE
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
BARIELUP
Authorized Official Title or Position:
ADMINISTRATIVE OFFICER
Authorized Official Telephone Number:
520-304-8856

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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