1346997392 NPI number — RISING STAR BEHAVIOR HEALTH LLC

Table of content: (NPI 1346997392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346997392 NPI number — RISING STAR BEHAVIOR HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RISING STAR BEHAVIOR HEALTH 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:
RISING STAR BEHAVIOR HEALTH LLC
Provider Other Organization Name Type Code:
4
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:
1346997392
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
546 E PASTURE CANYON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN TAN VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85143-5814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-814-4693
Provider Business Mailing Address Fax Number:
480-452-0828

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
546 E PASTURE CANYON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN TAN VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85143-5814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-499-8868
Provider Business Practice Location Address Fax Number:
480-452-0828
Provider Enumeration Date:
03/09/2022

Additional Information

Authorized Official

Authorized Official Last Name:
ADDEI
Authorized Official First Name:
SIMON
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
602-814-4693

Provider Taxonomy Codes

  • Taxonomy code: 320800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 323P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: BH7360 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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