1649897414 NPI number — DESERT BOLT BEHAVIORAL LLC

Table of content: (NPI 1649897414)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649897414 NPI number — DESERT BOLT BEHAVIORAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT BOLT BEHAVIORAL 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:
1649897414
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
42201 N 41ST DR STE 160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANTHEM
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85086-3803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-527-0042
Provider Business Mailing Address Fax Number:
480-296-0002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42201 N 41ST DR STE 160
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANTHEM
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85086-3803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-527-0042
Provider Business Practice Location Address Fax Number:
480-296-0002
Provider Enumeration Date:
06/28/2020

Additional Information

Authorized Official

Authorized Official Last Name:
NKENDONG
Authorized Official First Name:
VALERY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
480-527-0042

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 120200727001036 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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